In parallel to our meeting with the tribal nations, we had continued our state-by-state visits learning from mayors, governors, hospital leadership, and communities. After that first trip to Texas, Arizona, and New Mexico, Irum and I made three other trips, visiting seventeen other states, some for the second time. In the Southeast—Louisiana, Mississippi, Alabama, South Carolina, and Georgia—I got an eye-opening glimpse of the level of distrust people felt with regard to the federal government and the vaccines now in development.
Arriving in Baton Rouge, we thought we’d wandered onto the set for a postapocalyptic movie; there were so few people around. At a Starbucks—its furniture was pushed into a corner and walled off, and its bathrooms were locked—I asked a barista about Governor John Bel Edwards and the mitigation efforts in place in the state. New Orleans had been especially hard hit in the spring of 2020, but the summer was different: this time, the virus had spread rapidly across the state, leaving no county untouched. In rural communities and rural community hospitals across the South, the most complex cases like Covid-19 patients are transferred to regional medical centers in urban areas. Because those hospitals were already full with patients from urban communities, they often couldn’t accept patients from those rural areas. Consequently, without more advanced medical care available, those rural patients often died at a greater rate than their urban counterparts.
Now, with classes resuming at Louisiana State University in the next month, I was eager to understand how state officials were going to approach the return of students and the resumption of social gatherings. “People have been doing what they should,” the Starbucks barista told me, “but I’m starting to hear more and more about parties at people’s places.” I thanked her for the caffeine injection and the intel. Later, I had reason for greater hope. LSU’s administration and athletic department had instituted a surveillance system so that its highly successful football program and other sports could be a “geaux” for the fall. A few of those parties the barista had mentioned had the football program stumbling out of the gate, but its voluble coach assured me that once he reminded his players that their personal choices had an effect on their teammates and could jeopardize the entire season, they fell back in line, reducing gatherings, parties, and bar activities to ensure that a treasured community activity was kept in place. After a brief blip in rising cases at the beginning of the fall semester, active cases throughout the state declined until October. A month after our visit to New Orleans, in mid-August, while on trip number four, we would see the same situation with high school football in West Virginia. Shared community values could bring people together.
Across the board, southern states either had mask mandates in place statewide or were specifically encouraging local officials to implement them. After our continued engagement, even Georgia had moved to this approach. After our conversation with Governor Tate Reeves, who’d taken office in January 2020, we were pleased to see Mississippi, a state with significant comorbidities, put in place mask mandates on August 4. That was the best way forward: targeting mitigation to the specific areas where the data showed the burden was highest. Letting people know that the need for masks was urgent right then and right there, rather than everywhere and at all times, eased resistance to these measures.
Throughout the South, we saw new solutions, too. In Mississippi, state health officials were reaching younger residents through Instagram. In other cases, public health leaders used texts rather than calls to alert residents to guidelines or the need to test. Tailoring the message to specific subsets of the population and addressing their specific concerns and needs was the way forward. In Louisiana, the use of wastewater analysis to understand community spread allowed the state to alert communities of the need to practice enhanced mitigation. Alabama, under the leadership of Governor Kay Ivey, was aggressively mitigating against community spread using data. In Arkansas, Governor Asa Hutchinson and his team wrote a children’s book, The Kids Guide to the Coronavirus, to distribute through the schools. It included valuable information about preventing SARS-CoV-2 infection and about the coming vaccines—educating children and the adults reading the book to them at the same time.
Farther north, in the earliest days of the pandemic, Governor Mike DeWine of Ohio and his team had crafted a short video, “Back Up, Mask Up, Wash Up,” to educate kids on the three main mitigation strategies. Later on, with the Dine Safe Ohio program, 95 percent of the state’s restaurants complied with limited dining capacity, enforced masking, and expanded outdoor dining. You can craft the perfect plan, but if people don’t comply with it, it may as well be worthless. Ultimately, it took our being on the ground in all these states to recognize each one’s unique demographic, but also, happily, how fully each was using strong mitigation to ensure both health and economic progress.
The approach to masking varied from state to state and within states. What was important was masking indoors, not outdoors, but this message wasn’t always clear in a given state’s mandate. In Indianapolis in the last week of July, when Irum and I were on our third trip out to the states, a girls’ basketball tournament was being held, and as we walked the streets of the capital, we saw more ice-cream cones than masks covering faces. This latter didn’t bother us as much as what was happening indoors. There were excellent outdoor dining options, but with so many people in the city, many were pushed indoors just to get dinner. In many cities across the country, mayors had altered traffic patterns and regulations to dramatically expand outdoor dining. It was key for residents to understand that engaging in outdoor activities while unmasked was safe, and that outdoor dining was very safe compared to indoor dining. Still, when mandates were issued, rather than merely limiting indoor dining, state leaders often closed all restaurants. This approach unfortunately drove residents from safer outdoor dining to unsafe gatherings in homes.
Elsewhere—in Chicago for example—outdoor dining was prevalent, as were masks on diners and others, including waitstaff. We appreciated all attempts to protect workers at higher risk of exposure, with diners required to put on their masks when waitstaff approached their tables. Chicago’s mayor, Lori Lightfoot, was an exemplary leader in many aspects of the mitigation effort. Also, the entire metropolitan area’s private-sector hospital teams had transcended the sense of competition among hospitals that had been business as usual before the pandemic to create a unique, unified dashboard to ensure that every resident got to the right hospital, with the right equipment from ventilators to extracorporeal membrane oxygenation (ECMO) where their care could be optimized.
I wanted every American to see what I was seeing, the parts of the pandemic response that weren’t being covered in the media, the underlying practical solutions that were saving lives. Private-sector companies, looking past profit to support communities and states in their response, stepped up in unique ways across the country. In state after state, I saw competitors become colleagues, to save more lives. I saw this on the federal level, too: Hospital suppliers such as McKesson, Cardinal Health, AmerisourceBergen, Henry Schein, and Medline Industries used our epidemiologic data to align critical supplies with hospitals, to ensure that all hospitals, independent of their ability to pay, had the supplies and treatments they needed to respond to the health needs of their communities.
To gauge how effective we were, and how we might alter our messaging, everywhere we went, Irum and I queried hotel staff, counter clerks, and drive-thru attendants—anyone who could give us insight into what was happening on the ground and how people felt about the pandemic response. What we found was always a mixed bag of gains and losses. From these encounters, we learned that people perceived the pandemic as an “urban problem.” In rural areas outside Des Moines, Lincoln, Tulsa, Little Rock, and Charleston, West Virginia, people believed that, because of their geographic remoteness from urban centers, they were “naturally social distanced.” We heard this many times, and included warnings against this faulty belief in all the state governor’s reports. We had learned from the summer surge that rural areas were under as much threat from full Covid-19 disease as urban areas. Critically, rural areas often relied on urban hospitals for the care of the severely ill. With the summer surge, both urban and rural hospitals had become overwhelmed, and community hospitals were often unable to move their patients to the at-capacity regional medical centers.
On our fourth trip out, this time to the heartland, post–Scott Atlas, I engaged in a fruitful conversation with a Nebraska state health official who was genuinely interested in hearing our take on herd immunity. He opened the conversation by noting that this was how they handled infectious outbreaks in livestock in the Midwest.
Irum and I went through what we knew and didn’t know about Covid-19, including the duration of natural immunity after someone was infected and the unknown long-term impact of Covid-19, which had come to be referred to as “long-haul Covid.” We knew that, in the short term, infected young people did quite well, but we didn’t yet know if later complications from infection would appear months or even years in the future.
I don’t know if we convinced the official that “culling the herd” wouldn’t work, but at least he had an open mind. I always appreciated it when people asked questions and shared what was on their mind. Being able to talk through these issues was critical, but with the official’s mention of herd immunity, my eyes were once again opened to the damage that Scott Atlas and his group of like-minded doctors were doing.
NO MATTER WHERE WE went, we heard two things without fail. Every leader and nearly every American wanted to protect the old and vulnerable while charting a path forward for the young and less vulnerable. The former meant preventing Covid-19 from sickening and killing the elderly and those with severe underlying comorbidities; the latter meant not jeopardizing the education or future prospects of those in schools, small businesses, and working in the hospitality industry. We put out the message that testing and masking brought both those aims together.
So, with the cold weather approaching and driving up cases, Irum and I had set out on the fifth of our trips in the last week of August with these two groups very much in mind.
If we had been teaching a course, the main bullet points would have been:
In September, conveying this message had become more urgent than ever. Some states seemed frozen in time, still using tests mainly to confirm the presence of the virus in people with symptoms or exposure to someone with symptoms—that is, testing less than half of those infected and spreading the virus. The president’s calling for less testing and Scott Atlas’s influence with CDC testing guidance were both culprits. Their shift in messaging to fewer tests had produced a significant reduction in testing. That had to be countered.
Scott Atlas’s message that the task force believed all schools should be closed also had to be countered. We wanted schools open. We also wanted those who attended them and worked in them to be tested regularly to keep them from carrying the virus into the classrooms, dormitories, off school grounds into businesses, and to the multigenerational homes they lived in or visited. If we applied what our previous visits to the states had revealed, what had worked at some universities, to more of the population, we’d be able to offset one major failing: the persistent nearly 10 percent fatality rate in those over age seventy. To one degree or another, nearly everything we’d done had driven that rate down from nearly 30 percent in March and April, but even with all our advances in treatment, the rate of death from Covid-19 in this age group stubbornly remained at nearly 10 percent. Yes, it was a 66 percent decline from the earlier, higher rate, but the death of one in ten people over seventy with Covid-19 was still horrific to contemplate, especially with the mostly deadly surge on the horizon.
In our travels, we’d seen how governors had prioritized aggressive mitigation to protect nursing homes and long-term-care facilities. Irum and I had met with plenty of nursing home directors and heads of associations who oversaw and supported those operations. Following guidance from the Centers for Medicare and Medicaid Services (CMS), they had collected the necessary data. The National Guard had supported PPE distribution and testing, and CMS, in partnerships with states, had set up site-specific strike teams at the first evidence of an outbreak.
In mid-August, Irum and I had driven to a nursing home in suburban Oklahoma City that was part of Leading Age Oklahoma, a state association of not-for-profit organizations that provided services to aging populations. Pulling into the parking lot outside the main housing area, we saw folding chairs clustered outside windows—a stark reminder of what isolation had meant and continued to mean for those inside such facilities and their concerned family members kept outside.
Once inside the community room, for a meeting with staff and residents, we were all masked, but the staff’s eyes told me a lot. Their fatigue, their distress, and the collective trauma they had suffered were all evident there. These people needed to talk. Over the next couple of hours, care workers shared their heartbreak, their fears, and their desire to carry on working 24/7 for the home’s residents.
At one point, one of the residents, a woman I estimated to be in her early eighties, spoke. Her voice was steady and sure as she began thanking and praising the staff who had cared for her and others. Her voice rose and fell, halting and then rushing on. “My room became my prison. I ate there. Slept there. Bathed there. At the beginning, I thought, Well, okay. This is what it is, and it will just be for a little while. We’ll get through this. I didn’t see anyone for weeks. Weeks became months. I was behind closed doors and only saw one of the staff a few minutes a day. When they brought in my meal, my medication. I wanted them to stay, but I knew I shouldn’t take up too much of their time. They had so many of us to look after.
“Then, as the weeks went on, I was told about my friends and others who’d died. We didn’t get to say goodbye. Before the pandemic, others had died, but we’d have a memorial service of some kind to remember and recognize their time with us, but we couldn’t [do that] anymore. We couldn’t share memories. We couldn’t comfort one another. Everything just went flat, gray. It was all kind of matter-of-fact. ‘So-and-so died. They’re gone.’ I noticed, after a while, that the aides and the nurses spent more time with me. They lingered a bit. We talked, and I could hear it in their voices: They had more time because—well, because there weren’t as many of us to tend to. I started to wonder if all we were doing was worth it. Was this living when you were nothing but lonely and sad?”
Her words made everyone in the room emotional. Irum and I were there, in part, not just to listen, but to offer everyone another way through this; to deliver a warning, but also hope, in the form of a reliable, testing-based solution. Still, the fatigue was palpable.
As summer turned to fall, and I spoke with more governors and members of communities, I heard expressions of exhaustion like this one. The tone of the conversation had turned. People were beaten down. The mixed messaging, the sense that nothing we’d done before had worked, doubts that any other approach might work, the sense that we were drifting like a leaf on the wind—all these had settled in. This had to be countered. We had to show that strategic testing to identify asymptomatic spread was working elsewhere.
I had learned from my time in the military that you can’t stay at “up tempo,” on high alert, forever. You need to adjust your level of alert up or down based on the threat at hand. Regularly testing younger people to protect the older, most vulnerable could offer peace of mind, helping older residents get through the hardship they’d had to endure.
Nowhere was this more apparent than at America’s colleges and universities.
ALL ALONG DURING OUR visits to the states, under the leadership of Vice President Pence, we’d been meeting with higher education officials, and throughout the spring and summer, we’d been holding conference calls with educational leaders. They would share with us their plans for reopening in the fall and their contingency plans in case of a wide outbreak. We’d provide general insights, most specifically about the importance of regular testing not just testing those with symptoms. By the time we returned to Washington at the end of the first week of September, schools had reopened for the fall. For the most part, we had been impressed by the solutions-based approaches many higher education institutions had put in place to open safely. Now we’d get a chance to study the effects of their level of preparedness and see if theory matched reality.
Despite the success we’d seen earlier in the summer—with southern universities handling sports teams by regularly testing and immediately isolating those infected, thus preventing spread—initially, the full reopening of colleges and universities raised alarms.
What had happened with the North Carolina university system was particularly alarming. North Carolina’s university system had paused in-person schooling in late August, going fully remote by September 4 and remaining remote for the entire fall semester. The University of North Carolina at Chapel Hill had opened for in-person learning on August 10. The sheer number of students who tested positive that first week, and who had to isolate and quarantine, overwhelmed the system. The administration moved all classes online. Similarly, North Carolina State University, which had also opened with in-person classes, moved to online only a few days after UNC Chapel Hill; as did East Carolina University. This involved nearly ninety thousand students across these three universities. We wanted to meet with them to find out what had and hadn’t worked, and then immediately get to other large land-grant universities elsewhere. We couldn’t have thousands of students away from home, in leased housing in the community, without access to testing.
In a meeting with us, the UNC system representatives made their case that they’d done all the right things: they’d modified buildings and classrooms to enable social distancing; moved communal activities like their dining services outdoors or offered meals to-go, limiting the size of student congregations; and had imposed a strict mask mandate—just what other universities had also done since the start of the outbreak.
To their credit, students at UNC Chapel Hill recognized the role they played in viral spread, citing the reckless behavior of some that had put the health and education of others in jeopardy. The student newspaper, the Daily Tar Heel, and its editorial board joined many in denouncing the UNC administration for failing to anticipate the kind of behavior some students would engage in and for doing too little to “dis-incentivize” it. I was concerned about how much the UNC system had emphasized symptomatic over wider routine regular testing of all students independent of symptoms as an essential component of mitigation, and I wondered what these students could now do on their own. The data we’d been gathering from the universities that were testing all student athletes revealed a noteworthy trend. Among those in the eighteen-to-twenty-five age range who tested positive, between 90 and 95 percent were asymptomatic and accounted for the majority of student-to-student spread.
After our meetings ended, I called Brett Giroir to discuss what we’d found. I was really concerned with UNC’s stance on remaining fully remote, as most students lived off campus—nearly 85 percent of them in apartments with fully paid leases. For this reason, I believed that many students would remain in the community, in the apartments they’d already paid for—but without regular testing. Brett understood, and he immediately sent federal teams to expand community testing to the areas around the now-closed UNC system campuses. He didn’t wait until it was a crisis and hospitals were filling; he was willing to be proactive and get federal support there quickly.
The University of South Carolina, Columbia, demonstrated how good planning, linked to continual data collection, produced a flexible program that could be adjusted based on changing data and other findings. The university’s agile, responsive leadership tested 1,300 students per day. Based on the data and the university’s ability to scale up its own labs’ testing capacity, that number rose to 4,000 per day to nearly 50 percent of the student body weekly. With an enrollment of more than 35,000 students, that figure wasn’t 100 percent weekly but they were making progress and significantly expanding testing, testing every student, every week, those without symptoms as well as the symptomatic.
Within its own university laboratories, USC Columbia developed a means to test wastewater to detect the presence of SARS-CoV-2 in dormitory complexes. Louisiana State University, Clemson University, and the University of Connecticut also used this method successfully. Critically, they not only used it on campus but in the community to understand on- and off-campus viral spread to provide early alerts to trigger early response. We were encouraged to see universities’ proactive approach to asymptomatic spread and testing and their use of their own researchers and vast stores of equipment to find solutions. We actively encouraged other universities to do the same. Relying solely on the federal government or the state to act was not ideal. As with tribal nations, these large universities were nearly closed systems, bound by a sense of purpose and community. Taking agency over their own needs and priorities fit into a pattern of communities breaking free from a one-size-fits-all approach.
Universities are the backbone of much of the country’s basic research activities—with many primarily funded by the National Institutes of Health—and would be critical in a crisis like this one. Yet, when universities closed in March 2020, their research laboratories across the country were also shuttered, and research technicians and postdoctoral students went home. As a result, research and innovation across the country declined. We felt this loss throughout the spring and summer of 2020. Our scientists in the public and private sector are the envy of so many other nations, but the core of our basic research is done at our universities.
The contribution of many of these institutions to the pandemic response—the data people at Johns Hopkins being one of the earliest and most helpful—was undeniable, but without a pandemic preparedness plan that made use of the depth and breadth of their research scientists, their influence became limited. In this, I saw early on the evidence of yet another missed opportunity, one that had contributed to our being caught flat-footed at the outset of the pandemic and beyond. Although each university did a small amount of voluntary SARS-CoV-2 research, this effort wasn’t organized, it wasn’t done in a comprehensive manner, and it didn’t ask or answer all the questions we had. We needed all our university researchers available in March through June, but many were at home. For the next national health crisis, university researchers who receive federal funding need to be available to contribute their expertise to finding solutions. This should be part of the pandemic preparedness plan and pandemic response moving forward. All universities receiving federal research dollars should be required to attend a weekly meeting at which leaders assign essential, timely research questions to experts in the behavioral and medical sciences so we can build the new evidence needed to combat new pandemics in real time.
Among the universities that opened for the fall 2020 semester and stayed open, it wasn’t just medical scientists, researchers, and students who contributed to the pandemic response. Various universities and colleges enforced isolation and quarantine regulations and practiced contact tracing—which was effective but also time consuming; as was mandatory testing. One benefit of institutions of higher learning is that these schools have enormous information technology departments, with students and faculty who have studied computer science. IT departments at several schools—USC and “Ole Miss” chief among those we visited—developed phone apps to help with contact tracing, and Virginia Tech overcame the testing supply deficit by using 3-D printers to produce their own swabs. There and elsewhere, universities used their own research facilities to overcome the testing and processing shortfall. Across the country, it was all hands on deck, with people rising to meet the pandemic’s challenges.
Our trip to the Carolinas taught us something else: If what had happened with the UNC system were repeated elsewhere, a flood of younger people driving community spread would cascade across the country. A good plan required vigilance. It was clear what students were doing while on campus and in classrooms, but what they were doing outside these places likely contributed greatly to the transition back to remote learning. Irum and I were so concerned about the effects of these school closures that we canceled plans we had to go to California. (Steve Hahn and Jerome Adams would go in our place to better understand the continuing viral spread among agricultural workers there and in Oregon and Washington.) Irum and I would again focus on schools in the Southeastern and Atlantic Coast Conferences. Eventually, into the fall and winter, I’d visit more than thirty campuses.
Other trends and insights coalesced during these school visits. Irum and I were enormously impressed by the student body leaders, who were actively engaged in supporting mask use to protect the community. Rather than viewing mask mandates as a regulation being imposed from above, they transformed this perception into a grassroots campaign that felt organic to the mission of a university: to enlighten and expand one’s view beyond parochial interests. Simply put, they wanted to take care of one another and of their university’s faculty and staff and, in turn, the larger community and family and friends they would return to back home. These student leaders embodied the kind of selfless spirit we all needed to get through this crisis. Talking with these students, I felt that the sense of community was alive and well at our universities.
A roundtable with students at the University of Alabama was especially eye-opening. There, we learned that many of their classmates needed to remain on campus because it was the only place where they had a bed, a desk, and reliable access to food. With the university kept open, local businesses were able to stay open, too, providing these students with work, so they could afford books and tuition. A “virtual,” online university experience would have left them homeless, with neither job nor income, making them unable to stay enrolled. In-person schooling during a viral pandemic—with its masks and social distancing and canceled parties—may not have been pleasant, but for many students, it was a must. The students at the roundtable understood this, and many had started food banks for classmates who were less well-off and had become attentive to their mental health needs. This was community. This was what we’d seen with the tribal nations.
Ultimately, though, the role of testing emerged as the key takeaway. In the end, of the thirty-plus schools we visited, only 50 percent employed mandatory surveillance testing of every student. Often, schools tested only 3 to 5 percent of the student body, frequently the “worried well,” who got tested voluntarily, and not those who were at greatest risk. A version of what we saw in North and South Carolina was reproduced around the country.
Schools that required at least weekly testing of all students fared much better in the end than those that did not. I saw innovation in testing across the universities in New Hampshire: Plymouth State and the University of New Hampshire required weekly or twice-weekly testing, and they didn’t let dwindling resources stop them—spending their own money to keep their students and faculty safe. The University of New Hampshire was one of the most innovative, developing its own testing system on campus out of its genetics lab. UNH believed in its students, and trusted them to self-test twice a week, providing mailbox-like structures on campus where students could drop their nasal swabs. Students understood that this was the way for them to stay on campus and in class. This clear partnership between the students and the university administration showed that open dialogue and shared goals could result in successful Covid-19 mitigation.
And the proof was in the pudding! The data showed that those universities doing regular testing saw much less community spread among their student body. Here was the clear evidence, provided by the universities themselves. They had recognized the problem—that asymptomatic infection among Americans under thirty-five, which on average was close to 40–50 percent, rose as high as 75–85 percent (and in schools with mandatory schoolwide testing, to 95 percent)—and found a solution. Testing often and finding the asymptomatic cases in less than twenty-four hours from swab to notification prevented significant spread across the student body and allowed these schools to stay open.
The truth was simple: without regular testing of the asymptomatic, the effects of all the other good measures universities were instating would be diminished. We took our findings back to the task force and put them in the governor’s reports. We needed more regular testing and more rapid, youth-friendly turnaround on the results. We worked constantly to expand not just the sheer number of tests, but also this type of strategic testing. Unfortunately, the ongoing resistance of the FDA and the CDC to the rapid antigen tests limited our ability to move forward on testing at the pace needed. Throughout November and December, I worked with Brett to expand PCR testing and shorten the turnaround times, to make the testing better able to stop community spread. We moved nearly $400 million to support this effort in twenty regional surge sites—monies that could have covered three hundred thousand additional PCR tests per day across the country. This additional testing capacity, if consistently applied, would have brought us to well over two and a half million PCR tests per day. Unfortunately, the new administration didn’t prioritize testing, and though the money was there, they didn’t spend it, and this surge support testing didn’t happen until 2022.
Also, manufacturers planned to double production of the rapid antigen tests to one hundred million per month. With antigen and PCR tests combined, this would have resulted in a total of five million tests available per day. This plan would eventually be discussed with the incoming administration, but it took a backseat once President Biden was in office. Testing rates fell day after day, month over month, decreasing to three hundred thousand per day in June 2021. With warehouses filled to overflowing with unused tests in late spring 2021, rather than continuing to ramp up regular, inexpensive testing, as was done in the United Kingdom, manufacturers had to shut down their lines, and once again we entered the next surge, in summer 2021, blind to the early silent invasion.
WHAT WAS SUCCESSFUL IN the university environment could be used effectively at K–12 schools, offices, and other places. In late fall 2020, we again worked with David Rubin, director of PolicyLab at CHOP, to bring the same concept to a portion of the Philadelphia-area school system, and it was working; there was the evidence. Wherever regular testing was made routine and available, early infections were found and community spread prevented. What had worked in theory also worked in practice. This approach should have been universally adopted at all schools and workplaces in 2021. Unfortunately, it wasn’t. Instead, other, deeply entrenched issues hampered the testing effort.
Perhaps unsurprisingly, the failure in testing came down to money and a lack of faith among some at the FDA and the CDC that aggressive widespread testing could change the outcome of community spread. It may seem self-evident that if you test all students, staff, and faculty in a school, you will be able to head off silent spread. And while I got the sense that there was no real resistance among officials in higher education to the concept, the combined authorizations and priorities of the FDA and the CDA made this difficult.
Even the way the CDC reimbursed schools for surveillance testing stemmed from the agency’s belief that silent spread wasn’t a significant contributor to symptomatic Covid-19 disease and hospitalizations. The CDC operational plan allowed for colleges and universities to be fully reimbursed for symptomatic testing, but did not cover the cost of proactive testing to find the sources of new infections. As you can imagine, given the size of a standard university population, weekly asymptomatic testing is quite expensive. (My brother is the president of Plymouth State University, which has an enrollment of nearly five thousand students. His school spent nearly four million dollars on testing in the fall of 2020 and the spring of 2021.) Some schools and states were willing to foot the bill for broad, asymptomatic testing, using a portion of the CARES funds they’d received or whatever other monies they chose to use to offset the cost of their lifesaving vigilance. But not every school had that option. When Irum and I were in Missouri at a governor-sponsored roundtable, the president of Lincoln University (a Historically Black University and a land-grant institution) noted that the school didn’t have access to PCR equipment that it desperately needed to access routine testing. I called Brett and organized testing there and for all the Historically Black Colleges and Universities across the country. This was another illustration of how critical it was to learn the unique issues of various constituencies.
We had the testing tools that institutions of higher education needed to keep their doors open, avoid a negative financial impact, and prevent educational deficits in their student body. The CDC wouldn’t recommend proactive asymptomatic testing beyond 5 to 10 percent “surveillance” testing of a university’s population. This had forced these schools to make a difficult choice at a time when revenue loss was high. Everyone needed to be tested regularly. The CDC should have recommended that states conduct routine weekly testing. It had access to billions of dollars for testing to send to the states for K–12, community colleges, and universities, but it failed to ask states to prioritize the money for this effort—again, because it didn’t believe the role of silent spread was very great. This contributed to hidden community spread early on in the pandemic, leading to dreadful consequences down the line for more vulnerable people, as the strains that infected students made their way into nursing homes.
I applauded the schools that disregarded this federal disincentive and absorbed the cost of proactive testing. I also understood why some schools had opted out of this costly approach. They should never have been put in that position. All Irum and I could do in the face of federal agency intransigence was make the recommendation to the university presidents and public health officials, and in our weekly governor’s reports, that they should fund a comprehensive routine proactive testing plan. We also advised that, individually and collectively, university administrations exert additional pressure on the chief executive of their state, the person at the top of the hierarchy overseeing public institutions of higher education, the governor, to fund this testing. Vice President Pence, whose care and attention to the needs of such institutions of learning were particularly acute, made clear, in no uncertain terms, that colleges and universities needed to institute mitigation efforts that allowed them to stay open for everyone. Some schools listened; some did not. How much of this was due to funding is impossible to say.
Irum and I had seen examples of appropriate funding decisions producing great results. These, too, were added to the response plan for the remainder of the year and beyond. After the 2009 H1N1 outbreak, many universities across the country had received Global Health Security (GHS) funding. The same was true in 2015, when the potential for an Ebola outbreak beyond Africa’s borders was seen. At the University of South Carolina and in Tucson, Arizona, we visited two of the finest clinics and laboratories either of us had ever seen—both facilities were built, in part, using GHS monies provided by the HHS.
As with how CARES funds were distributed and monitored (or not), various public universities spent the money they received from the federal government at their own discretion. Some used the money to prepare for the next pandemic; others used it for other purposes. As was the case throughout, the federal government handed out vast amounts of money but didn’t attach any meaningful requirements to it regarding how it should be spent or for reporting those expenditures.
This wasn’t a recent issue. Year after year, the states submitted plans and funding requests, and the CDC and other agencies sent monies. There was no required reporting on the outcomes or impact of the dollars spent, as we had with our global PEPFAR funds. Holding the states accountable for the federal dollars they spend seems, at a minimum, a commonsense approach. At the schools we visited, Irum and I saw a range of funding uses—some that were brilliantly innovative and others that supported business as usual and didn’t contribute greatly to the pandemic response. As with so much of the pandemic, it came down to finding the right balance between control by the federal government and independence for institutions and states. The only way to ensure progress against public health issues is to hold each side accountable. An annual report on whether agreed-upon outcomes and impacts have been achieved with federal funds isn’t too much to ask.
At some schools—Texas A&M and the University of Kentucky, in particular—administrators were keenly aware that a top-down model with regard to the imposition of mandates wasn’t going to work with their student body. If you wanted students to comply with mitigation measures, open and transparent exchanges with them would be necessary. Although true in so many cases with this pandemic, ineffective communication got in the way. At these universities and many others we visited, students and administrators worked hard in partnership to craft effective and reasonable guidelines. We learned a lot from the students and the university officials. At many universities, like Texas A&M, we saw amazing leadership among the students—self-policing and ensuring that words were translated into action. In some instances, their wording emphasized what students could no longer do, instead of highlighting what they still could. Similarly, the University of Pennsylvania used pulse surveys (that is, regular, frequent surveys designed to take snapshots of public opinion) to assess how student perceptions about Covid-19 were evolving and devised a marketing strategy to respond to student input. At a time when so much of life during the pandemic felt out of our hands, people, not just university students, wanted to take ownership of the response.
Stony Brook University, in New York State, devised a simple method to get over the “You can’t do this” message. Rather than placing a red X or a D somewhere, to indicate where you weren’t allowed to sit, stand, or move, they used green arrows and dots to indicate where you could go, what you could do. Creating a sense of what was still possible helped offset the feeling that nearly everything had been taken away. As time went on, and Covid fatigue set in among us all, these subtle psychological reminders grew in importance.
If there was one universal, it was this: Nearly every campus that opened or that we visited had set up a comprehensive response team. Whether they had been prompted by an incidence of Covid-19 disease or some other catalyst, these teams created websites and other forums for sharing essential information that were unique to that particular campus or community. At the University of Kentucky—which tested all students upon their arrival to campus and required a daily symptoms check—when students tested positive or contact tracing revealed they’d been exposed to someone who was infected, teams leapt into action, delivering food, bringing the students needed school work and materials. When students had to isolate as a result of infection or quarantine after exposure, they weren’t completely cut off; they were supported. Examining every aspect of student life, the university did its best to meet the needs of those in isolation and quarantine.
Student mental health was very much a concern for university administrators, as it was for me. That included not just college and junior college students but those in K–12 schools. (More generally, we were well aware of and very determined to limit the mental health strains on everyone in America.) At one point during our preparations for issuing school reopening guidance, Elinore McCance-Katz, the assistant secretary of health and human services for mental health and substance (SAMSA), addressed us. Dr. McCance-Katz and the First Lady spoke eloquently on the pandemic’s severe effects on mental health. Frighteningly, there had been a decrease in reporting of child abuse. With schools closed, teachers and administrators, both of whom are bound by law to report any suspicions of abuse in the home, were no longer seeing children in person. I had been concerned about this since March. One of my daughters is a social worker and she knows this world well and how critical a partnership with teachers is in ensuring that children have safe homes to return to in the evening.
McCance-Katz presented deep and compelling data on the deteriorating mental health of our children, documenting increasing calls to help lines and emergency room visits rising for adolescents and young adults with suicidal thoughts and actions. We needed to address these issues and work across the agencies to provide additional guidance and work to get schools fully open safely. No one could argue with that. I understood this and was an ally in getting this information to parents, teachers, and school boards to support a road map to opening K–12 and universities safely. I believed it was possible to keep schools open safely with regular testing programs in place; getting enough tests to educational institutions was important.
Elinore McCance-Katz was absolutely right to raise these concerns. I wanted the CDC, as part of a whole-of-the-child approach, to include in their guidance to schools the overall mental health of our children and SAMSA’s concerns about suicide and safety. I wanted parents and school officials to be alerted to this growing mental health issue. McCance-Katz wrote and called and said she wasn’t getting any traction with the CDC to include these mental health issues in the school reopening guidance they were developing. I was so concerned that I wrote Bob asking the CDC to reconsider the McCance-Katz document that included data analysis and considerations developed by the NIH and SAMSA addressing the mental health alerts about depression, anxiety, and suicidal thoughts. With that included, parents and school boards could weigh this important aspect of in-person schooling while making decisions regarding reopening schools safely.
More than a year later, I was providing information about the Trump administration Covid-19 response to the special house subcommittee on Covid-19. A staffer pulled out the very email I had written to Bob implying this was yet another smoking gun demonstrating how the White House interfered with the CDC and their guidance. I was dumbfounded. These were smart concerned staffers but they had fallen into the same partisan divide. I responded that they should have been asking the CDC why they would not include the importance of the mental health of America’s children in their school guidance to provide a whole child approach. At every level we have turned this into a black and white, red/blue partisan issue, and we have lost any ability to see that even people who don’t agree with us can have critical insights and are worth listening to. McCance-Katz was worth listening to. She and her people were aware of the reality of decisions that impacted children and families. What they said was more important than any narrative other groups were trying to spin. It was also important, as we saw on these university visits, that the students themselves be heard at all levels of on-campus pandemic issues. They were key to helping change behaviors.
Another solution to mitigation resistance was direct involvement with student leaders and other influencers in the campus community. Reducing the traditional, top-down instructional hierarchy and replacing it with horizontal, collaborative teams provided a comprehensive approach to pandemic management. By conveying the notion that they didn’t know everything, and by getting input from all quarters on mitigation measures, school officials were able to create solutions and get buy-in from students. This further fostered a sense of community and responsibility, sending the message We’re all in this together, and if we take the time to listen to one another, we’ll find ways to resolve conflicts and build trust.
As with the tribal nations, the schools we visited evinced no interest in adapting a one-size-fits-all approach to student needs. We saw this clearly with student employment. It is easy to forget that many students and members of the community rely on schools for jobs, either to pay for tuition or housing or to otherwise support themselves. At Ole Miss, LSU, the University of New Hampshire, and the University of Alabama, the school administration, local county commissioners, and mayors cooperated to ensure that the surrounding towns’ commercial ventures remained open, to preserve as many of these jobs and work-study opportunities as possible. Cooperation between an institution and local authorities was critical to how the outbreak was managed. The University of Alabama administration went a step further to address student needs by allocating some of the CARES funds it had received to help students pay for their tuition or rent.
Housing circumstances affect college and university students as much as they do the rest of the American population. In Columbia, South Carolina, the mayor and city council were able to enact a measure banning house parties in rental apartments and houses. With landlords being held accountable to enforce this, you can be sure the message was passed along to student renters. When we visited the University of South Carolina, students there told us they had come onto campus fully expecting their university to go into lockdown—so they might as well party. The university’s proactive testing programs prevented this, and perspectives and momentum shifted. As the semester progressed, the students saw that their school was staying open and was committed to a Covid-safe campus environment. They now had a stake in preserving what most of them wanted—to have as full a college experience as possible in very difficult circumstances. These students were seeing that how they behaved had both positive and negative consequences for them and their friends.
Communal housing during a pandemic—in dormitories, fraternities and sororities, and shared apartments—presented unique challenges, and universities devised solutions to keep students safe. In Lexington, Kentucky, and elsewhere, the living quarters themselves played a role in how the outbreak was managed. Over the previous nine years, all dormitories had been overhauled—with two people living in one room and sharing a bathroom. This reduced the level of social contact compared with places like Ole Miss, where the dorms’ communal bathrooms made social distancing difficult and most likely contributed to viral transmission, despite all the good work their resident directors did. Similarly, when the University of Tennessee in Knoxville first opened, 680 students tested positive and 2,000-plus were put in isolation/quarantine. Many of the dormitories there had communal bathrooms.
At many schools where Greek life is a major part of the social scene, fraternities and sororities demonstrated their leadership by modeling mask wearing and chapter presidents were required by their national organization to enact contact tracing measures. Greek organizations even adapted their traditional membership rushes, turning them into virtual, online events. Contact tracing, both by university housing and the Greek organizations, illuminated the role of housing in the pandemic: When students wore masks in class and were properly spaced, extremely few instances of viral spread resulted. The vast majority of cases of Covid-19 resulted from social settings on and off campus. Transmission rates were high in Greek houses, not necessarily because their residents were partying, but because they shared living and eating spaces in a way many dorm residents did not. House mothers worked very hard to transform common spaces into safer areas.
From this we learned that adults living in communal spaces similar to a fraternity or sorority house needed regular testing to prevent spread. This applied to those working in shared spaces in offices and retail and service spaces, too. When preemptive testing programs ensured that infection was spotted quickly and the appropriate measures taken soon after, these places could remain open.
In the end, what was taking place at the universities represented a microcosm of the nationwide pandemic response and experience. I was heartened to see the innovation and flexibility at these schools, the willingness to listen and to respect others’ beliefs and needs. When everyone—students, faculty, and the administration—had a seat at the table in planning, implementing, and using data to revise their approach, it resulted in joint learning and evolution.
On one campus visit, in assessing their efforts and what they faced moving forward, the university president said, “Human behavior is hard to manage.” Yet, instead of giving up, the school had buckled down and brought students and faculty together, as a community, to listen, adjust, and overcome issues—all this in racially, politically, and ethnically diverse settings. They united around a single goal: to attend classes in person and not remotely, as they had had to do in March 2020.
Irum and I were inspired by their adaptability and their commitment to a shared goal and to one another. Whether the schools were in red states or blue states, they put aside their differences. This community-first spirit worked in the heat of the summer in the South and in the cold winter in the North—and provided us with a road map. Their planning was horizontal and not top down. Everyone’s voice was heard. They adapted. The administrations running these institutions believed in and trusted their students’ willingness and ability to understand both what they needed to do and the consequences of failing to do it. I couldn’t help but wonder how different things across the country might have been if the rest of us had acted with the same intention to protect one another.
These students and their community, and the tribal nation leaders and members we’d met, showed us that, now more than ever, we needed to focus on what united us, not what divided us, a point worth sharing—even as we entered the middle of the most divisive election season in modern history.