Why universities must move all teaching online this autumn
Number 99: #USSbriefs99
UPDATE: if you know of a UK University planning to teach all-online in the autumn, let us know on Twitter or by email and we will update this list
Although large numbers of US colleges and universities have decided to teach online this term, so far in the UK only University College London has taken this route. Virtually all other universities are stating that they will offer ‘blended learning’, i.e. some unspecified combination of face-to-face and online teaching. No doubt this policy is heavily based on financial considerations, reflecting the misplaced priorities of the sector since the start of the pandemic (see USSbriefs92). In general universities are supplementing the policy with exemptions for those staff who can prove they are at heightened risk if they catch Covid-19, for example by using the government’s vulnerability categories or alternatives such as the BMA-listed or Alama risk assessment tools.
In this brief we argue that: first, given the current UK prevalence of Covid-19, there is a significant risk that any given student or member of teaching staff who attends weekly face-to-face teaching events (lectures, seminars, workshops, laboratories) throughout the autumn term will catch Covid-19; second, that this risk extends indirectly to all workers on campus, including cleaners, professional services staff, and canteen staff; and third that anyone who catches Covid-19 is at significant risk of developing serious illness.
We conclude that any university that holds regular face-to-face teaching events will be putting the health of its students and teaching staff (and indirectly also its other workers and members of the local community) in danger, violating both its legal and moral responsibilities to them. Therefore, with certain exceptions that we lay out below, and in the absence of comprehensive and regular testing, universities must cancel face-to-face teaching this autumn and move to an all-online model.
1. The risk of catching Covid-19
In the course of August and September some 1.9 million UK students are due to move, mainly from other parts of the country, to new shared accommodation on campus or in university towns (HESA data). The Office for National Statistics estimates that in England and Wales currently around 500 per million of the population are infected, whether currently symptomatic or asymptomatic (see appendix). So based on the current prevalence we can expect that nearly 1,000 students will arrive at universities around the country carrying a Covid-19 infection, or on average five out of every 10,000 students at a given university. This figure ignores non-UK students as possible carriers, assuming that they will be asked to quarantine when arriving in the country. Furthermore recent estimates suggest that 70–80% of those infected at any one time are asymptomatic (Riley et al, 6 August 2020). So even if all students and staff who show symptoms are immediately tested this will pick up only 20–30% of carriers. Only universal testing on arrival would identify all carriers. At present, only the University of Leicester has promised this, and only on a voluntary basis (Leicester email to students, 7 August 2020).
A typical infected but asymptomatic student will move into a shared residential hall or household where the chances of passing the virus on to others in the hall or household will be high. In turn, infected students in a household or hall will have a significant chance of passing the virus on to students from others through social contacts. If in addition student carriers regularly go to teaching events they will have a significant chance of passing the virus on to other students both at the teaching events themselves (where they may also pass it to teaching staff and to staff who have to clean classrooms between sessions), and on the way to and from campus if they have to travel by public transport (where they may also pass it to other members of the community). It is easy to see how a small number of initial infections can lead to a major outbreak, as has already happened at the University of North Carolina at Chapel Hill, and the University of Notre Dame. The only way to ensure against this outcome would be by a comprehensive programme of testing all students and staff at least weekly (Paltiel et al, 31 July 2020).
It may be said that the social distancing, hand-washing and mask-wearing measures instigated by universities will prevent transmission at face-to-face teaching events. However these measures (with the possible exception of mask-wearing) are likely to be ineffective against indoor airborne transmission of the virus, for which there is now abundant evidence: see the articles collected here. The ventilation and air filtration usual in public buildings fall below the standards that would be needed to prevent airborne virus transmission (Morawska et al, 27 May 2020, section 2.1), and to our knowledge no UK university has announced that its aeration systems this coming term will meet such standards. Meanwhile of course the above measures will have no effect on the chances of students and staff catching Covid-19 on crowded public transport to and from campus.
Therefore at any given university there is a significant risk of an outbreak of Covid-19 among students this autumn term, which could become exponential, and therefore a significant risk to any given student that they will catch the illness. If in addition the university holds regular face-to-face teaching events, then the risk to any given student will increase materially. The risk will also extend to teaching staff, to cleaning staff, to other staff who work in student-facing roles, and indirectly to all other university workers, including some on the lowest pay scales, where women and BAME staff are disproportionately represented.
In the above we have focused just on the environment-based risk of catching Covid-19. We have not investigated the possibility that the individual risk of catching the disease may be higher for those in particular age groups or with particular medical conditions. Our point is that the risk to all students and staff will be significant.
2. The risk of serious illness from catching Covid-19
The usual measure of the risk from catching Covid-19 is the Infection Fatality Ratio (IFR): the percentage of those infected by the disease who go on to die from it. As is well known, in the case of young healthy people the IFR is extremely low. In our view this measure is much too narrow. We believe that universities are legally and morally bound to protect their students and staff not merely against death but more broadly against ‘serious illness’, in which we include not only an illness leading to death but also an illness severe enough to require hospitalisation, and also an illness with significant symptoms that persist over a prolonged period, even if it is ‘mild’ in the technical sense of never requiring hospitalisation (Callard, 8 May 2020). In the case of Covid-19 it is becoming increasingly clear that a significant proportion of people who become ill are suffering from ‘Long Covid’, involving debilitating symptoms that can last for months and in some cases show no sign of subsiding.
So the proper measure of risk from catching Covid-19 is the percentage of those infected who go on to develop a ‘serious illness’ in the above inclusive sense. Here we focus on the second and third components of that measure.
2.1 The risk of hospitalisation
It is clear that in everyday terms an episode of Covid-19 can be severe without requiring hospitalisation by the present criteria, which tend to focus narrowly on pulmonary symptoms when it is becoming apparent that Covid-19 is a multi-system disease. Nevertheless the ‘Infection Hospitalisation Ratio’ (IHR), which we define as the percentage of those infected who require hospitalisation, gives some indication of the risk of severe illness. A study of the first 44,700 cases of Covid-19 in China found the following IHRs for different age groups (Verity et al, 30 March 2020):
They indicate that the risk from catching Covid-19 of becoming ill enough to need hospitalisation rises dramatically with age, but is significant even for those aged only 30–39.
2.2 The risk of Long Covid and organ damage
‘Long Covid’ has by now become a recognised condition that afflicts not only older but also younger people, and even children. For an example, see Hannah Davis’s account of persistent fever and cognitive dysfunction months after contracting the virus. Other symptoms that have been medically identified include ‘breathing difficulties, enduring tiredness, reduced muscle function, impaired ability to perform vital everyday tasks, and mental health problems such as PTSD, anxiety and depression’ (NHS England announcement, 5 July 2020), ‘fatigue, a racing heartbeat, shortness of breath, achy joints, foggy thinking, a persistent loss of sense of smell, and damage to the heart, lungs, kidneys, and brain’ (Couzin-Frankel, 13 July 2020), ‘chest pain, headaches, neurocognitive difficulties, muscle pains and weakness, gastrointestinal upset, rashes, metabolic disruption […] thromboembolic conditions […] headaches, dizziness, and cognitive blunting (“brain fog”).’ (Greenhalgh, 11 August 2020). There are increasing indications that Covid-19 can have a long-term impact on mental health: in a recent study of 402 patients who had been hospitalised with the illness, 56% were suffering from at least one psychiatric disorder one month after treatment (Mazza et al, 30 July 2020) — a finding that should particularly concern university leaders aware of the high levels of student and staff mental ill health.
But what is the risk of someone developing Long Covid if they catch Covid-19? It can be measured by the ‘Infection Long Covid Ratio’ (ILCR), which we define as the percentage of those infected who go on to develop significant symptoms of Covid-19 over a prolonged period. There is little systematic research so far on the ILCR for populations as a whole, let alone for different groups (Alwan, 11 August 2020). However here are some recent findings.
(1) An American CDC study interviewed 274 adults who had tested positive for Covid-19, and had been symptomatic at the time of testing, a median of 16 days later. ‘35% of these symptomatic respondents reported not having returned to their usual state of health by the date of the interview […] including 26% among those aged 18–34 years, 32% among those aged 35–49 years, and 47% among those aged ≥50 years.’ (Tenforde et al, 31 July 2020)
(2) An ongoing study by Gregory Dore and colleagues has reported preliminary findings that ‘at least 20%’ of a representative sample of 72 sufferers from Covid-19 who had not been hospitalised had symptoms including breathlessness, fatigue, anxiety and “brain fog” three months after they had cleared the virus. The symptoms did not appear to be correlated with age. (McCauley, 23 July 2020)
(3) An analysis by Covid Symptom Study group found that 10% of people who reported symptoms on the group’s app, used by over 4 million people in the UK, were still experiencing ‘fatigue, headaches, coughs, anosmia (loss of smell), sore throats, delirium [or] chest pain’ more than three weeks after first reporting symptoms. (Covid Symptom Study, 8 June 2020)
Other studies using groups of patients who were all hospitalised, although in a large proportion of cases without requiring oxygenation, have shown much higher percentages with prolonged symptoms (Carfi et al, 9 July 2020, Arnold et al, 14 August 2020).
None of these studies has the denominator we need, namely a number of those infected as opposed to symptomatic. Estimates of the proportion of those infected who never develop symptoms vary widely, but two recent studies put the figure at 42% (Lavezzo et al, 30 June 2020) and 19% (Wells et al, 30 July 2020). If we take the average of these then for every 70 symptomatic cases in a population there would be another 30 who are infected but never become symptomatic. Adjusting the above percentages accordingly (multiplying them by 70/100) we can derive from the three studies estimated ILCRs of about 24% at 16 days, at least 14% at three months, and about 7% at three weeks. Meanwhile the CDC study suggests that people aged 18–34 had an ILCR three quarters as high as the average across all ages while the Dore study has found no correlation with age at all.
Suppose we take the most conservative finding (from the Covid Symptom Study) — and adjust it by the largest age group discrepancy (from the Tenforde study). We would conclude that people aged 18–34 who catch Covid-19 have a 5% chance of suffering symptoms for more than three weeks. However this estimate is subject to a high degree of uncertainty given that the Dore study suggests a much higher figure.
This figure also fails to take into account indications of what we could call ‘Invisible Long Covid’, in which there is long-lasting organ damage that does not manifest in the form of noticeable symptoms but rather in an increased incidence of, say, strokes or heart attacks. For example, another study investigated 100 Covid-19 patients of median age 49, two thirds of whom had not required hospitalisation. It reported that at a median of 71 days after diagnosis 60% of the patients had ‘ongoing myocardial inflammation’, and 78% had abnormal cardiovascular MRI readings (Puntmann et al, 7 July 2020). As Megan McArdle has argued in the Washington Post, ‘If these results turned out to be representative, they would utterly change the way we think about Covid-19: not as a disease that kills a tiny percentage of patients […] but one that attacks the heart in most of the people who get it, even if they don’t feel very sick.’ Meanwhile other studies have suggested that Covid-19 can cause long-term damage to the liver, kidneys, stomach, eyes and central nervous system (Gupta et al, 10 July 2020), as well as the lungs (Vasarmidi et al, 9 July 2020).
To summarise: first, if a university holds regular face-to-face teaching events for its staff and students then, given the current UK prevalence, it will put staff at significant risk, and students at significant additional risk (beyond the risk from shared accommodation and social contacts) of catching Covid-19.
Second, the risk from catching Covid-19 of becoming ill enough to need hospitalisation rises dramatically with age but is significant for all staff aged 30–39 or above. Furthermore the risk from catching Covid-19 of developing Long Covid for both students and staff of all ages is significant but uncertain, and that of developing long-term organ damage cannot be discounted. So the net risk of serious illness for both students and staff of all ages is significant.
Putting these together, we conclude that, again given the current UK prevalence, if a university holds regular face-to-face teaching events it will put both students and staff at significant risk of serious illness. We do not see how this is compatible with the general duty of employers to their employees under the Health and Safety at Work Act 1974 section 2:
It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.
Without prejudice to the generality of an employer’s duty under the preceding subsection, the matters to which that duty extends include in particular
the provision and maintenance of a working environment for his employees that is, so far as is reasonably practicable, safe, without risks to health, and adequate as regards facilities and arrangements for their welfare at work. (our emphasis)
nor with general duty of employers to persons other than their employees, in this case principally to students, under section 3:
It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety. (our emphasis)
Furthermore we believe the above duties are not just legal duties but also moral ones: specifically duties of justice towards staff and students.
Exempting students and staff who can prove they are at ‘higher risk’ from catching Covid-19 from face-to-face teaching, whether based on government categories or on a medical risk assessment tool does not change the picture, for the significant risks we have identified in this Brief apply to all students and staff regardless of their personal medical conditions, not just to those at ‘higher risk’.
Allowing students and staff to participate in face-to-face teaching on a purely voluntary basis, whether through an opt-in or an opt-out mechanism, also fails to address the issue. Simply by advertising face-to-face teaching and making it available, a university puts those students and staff who choose to participate in it at significant risk, again regardless of their personal medical conditions.
Furthermore, if academic staff are allowed to withdraw from face-to-face teaching either on medical grounds or simply on a voluntary basis, there is a real danger that those staff who have more power within the institution will find it easier to withdraw. Face-to-face teaching duties and their attendant risks will be offloaded onto junior staff, and especially staff on zero hours contracts and GTAs, who are subject to greater formal and informal pressures from line managers. In turn these staff are more likely to be women and/or BAME. It will be practically impossible to enact a policy of selective exemption that is not discriminatory towards women and staff of colour.
We conclude that this autumn, and for as long as UK prevalence of the virus remains at or near present levels, in the absence of comprehensive and regular testing of all students and staff, UK universities must cancel face-to-face teaching and move instead to an all-online teaching model.
We make an exception for what we call ‘Covid-essential’ teaching — teaching that is essential to the fight against Covid-19 and that can only be carried out face-to-face. In such cases universities should carry out harm-benefit and equality analyses to determine whether the teaching should go ahead and who should be asked to take part in it. Here individual risk assessment tools like those we mentioned at the start can play a role. The same applies for ‘Covid-essential research’. In fact we would argue that an indiscriminate policy of face-to-face teaching is positively harmful to such Covid-essential activities, since it raises the likelihood of an outbreak on campus that will threaten the suspension of virtually all activities.
Although we have focused on teaching, we believe that what we have said here applies to all on-campus work, including IT, library, administration, cleaning and canteen work. The underlying principle should be the same: where on-campus work can be replaced by remote work (as is clearly the case with almost all teaching) then it must be. Where it cannot be, then the decisions as to whether to continue or discontinue it, and if it is continued then who should be asked to undertake it, should be taken strictly on the basis of harm-benefit and equality analyses.
Appendix: Office for National Statistics prevalence estimates in England and Wales
This paper represents the views of the authors only. The authors believe all information to be reliable and accurate; if any errors are found please contact us so that we can correct them. We welcome discussion of the points raised and suggest that discussants use Twitter with the hashtag #USSbriefs99; the authors will try to respond as appropriate. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.