Dean's COVID-19 Commentary

In a 1976 book, On Acceptable Risk: Science and the Determination of Safety, William Lowrance defined safety as: “a thing is safe if its risks are judged to be acceptable.” I have long used this definition in framing problems in risk for its universality. It fits well with dilemmas posed by the challenges in decision-making around the pandemic, as we make efforts to reopen and edge towards “normalcy.” The definition has two implicit elements: what are the risks and are they acceptable? Uncertainty about the magnitude of risk often clouds decision-making, and judgements of acceptability as to levels of risk vary among people and populations. We see those differences in judgments around indoor dining, for example. 

Let’s apply Lowrance’s definition to the reopening of schools, a current hot topic following the release of the new recommendations from the Centers for Disease Control and Prevention (CDC): Operational Strategy for K-12 Schools through Phased Mitigation. The words safe and safely appear throughout the strategy, as with these two consecutive sentences: “It is critical for schools to open as safely and as soon as possible, and remain open, to achieve the benefits of in-person learning and key support services. To enable schools to open safely and remain open, it is important to adopt and consistently implement actions to slow the spread of SARS-CoV-2 both in schools and in the community.” The first quoted sentence implies a risk (that of SARS-CoV-2 infection) versus benefit (those of school attendance) balancing. Do we know enough to find that point of balance and could consensus ever be reached on where that point lies?

There has been much public conversation on this balance. Much of that discussion has centered on whether teachers and other school personnel need to be vaccinated before returning to classrooms and schools. Through the lens of school personnel, the increment in risk from returning to schools, rather than teaching from home, may be unacceptable. On vaccination, the CDC recommends: “Vaccination for teachers and school staff, and in communities, as soon as supply allows.” In Colorado’s most recent vaccination distribution plan, the state’s PreK-12 personnel are in Phase 1B.2, now underway.  

Considerations of risk and uncertainty and the acceptability of risk reach widely across decision-making. Last week, I briefed the Environmental Protection Agency (EPA) on a new report from the National Academies of Science, Engineering and Medicine on risk evaluation under the 2016 revisions to the Toxic Substances Control Act (TSCA): The Frank R. Lautenberg Chemical Safety for the 21st Century Act. I chaired a consensus committee that began its work a year ago, tasked with examining the methods by which EPA carried out systematic review to assess the risks of chemicals. The focus on characterizing risk as a step towards judging safety fully parallels decision-making with regard to the COVID-19 pandemic: assembling evidence to capture what we know and to identify what we do not know. My committee was not charged with determining safety but with reviewing the EPA’s methods for amassing the best evidence for doing so. Over the last decade, systematic review has become the starting point for making judgments about the risks and safety of the myriad environmental agents that affect human an ecosystem health.  

Our campus has expanding expertise in systematic review and evidence synthesis and integration with the recent recruitments of Tianjing Li and Lisa Bero to the CU School of Medicine and ColoradoSPH. Lisa has founded the Colorado Evidence System Program with the following mission: “Promote the generation and use of trustworthy evidence to inform decision-making at the individual level and at the health system and population level.” The new program kicks-off today with a three-day virtual meeting, Methods Symposium: Advanced Methods and Innovative Technologies for Evidence Synthesis. Advance sign-up was close to 1,000, signaling the critical and cross-cutting role of evidence synthesis. 

One unanticipated risk of the pandemic has been the threats to public health personnel in response to implementation of epidemic control measures. A chilling story in yesterday’s Denver Post describes the threats, including protestors appearing at the homes of directors and doxxing (finding and releasing personal and identifying information). Such threats are contributing to a loss of public health personnel, including 19 public health directors from 54 agencies in Colorado. As if a pandemic were not enough!

Stay warm and stay well, 

Jonathan Samet, MD, MS
Dean, Colorado School of Public Health