Copy of My Open Letter to the BU School of Public Health Community

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

 

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

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

3. We don’t put financial interests above health

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The answer is quite simple: money.

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

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

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

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

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

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

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

Conclusion

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

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