On June 14, CBS’s 60 Minutes aired a segment called “The College Test” during which the University of North Carolina at Chapel Hill (UNC-Chapel Hill) unveiled “Carolina Roadmap,” a highly detailed plan for opening the university, which has been shuttered since March, for on-campus instruction during the 2020 fall semester. Students began arriving on campus Aug. 3. On the first day of class, Aug. 10, 1 student tested positive for COVID-19. By Aug. 17, there were multiple COVID-19 clusters, with hundreds of infected students living in campus dorms and off campus sororities and fraternities, resulting in UNC-Chapel Hill abandoning on-campus instruction for remote, online instruction. What happened and what lessons can we learn from UNC-Chapel Hill’s disappointing experience?

If ever there was a public university with the intellectual horsepower to make in-person instruction during a pandemic work, UNC-Chapel Hill was the place. Dr. Kevin Guskiewicz, a highly-respected traumatic brain injury researcher and MacArthur Fellow, had recently been named Chancellor of the university. The Schools of Medicine and Public Health provided a deep bench of expertise— world- renowned coronavirus researcher Ralph Baric; clinical care teams led by Dr. William Fischer and Dr. David Wohl, veterans of the Ebola outbreaks in West Africa and the Congo; teams involved in COVID-19 vaccine development; availability of convalescent COVID-19 plasma therapy; and monoclonal antibody development. Dr. Melissa Miller, who developed PCR tests for SARS-CoV in 2002 and H1N1 influenza A in 2009, along with her team, had developed a SARS-CoV-2 molecular test with emergency use authorization (EUA) from the U.S. Food and Drug Administration (FDA). Guskiewicz and Dr. Robert Blouin, the university Provost, worked with the best and the brightest the university had to offer to develop Carolina Together, a website providing the Carolina Roadmap, with information for students, their parents, faculty, staff and the community on how the university would function for the fall 2020 semester. Central to this plan were Community Standards, to which the faculty, staff and students would be expected to adhere. Importantly, everyone in the campus community was to wear masks, maintain physical distances, self assess for COVID-19 symptoms and not attend social events with more than 10 people inside or 25 people outside.

During the month of June, the UNC School of Public Health surveyed students about their public health attitudes during the pandemic. Key survey findings were that 82% of students wanted to return to campus, 84% of undergraduates would be willing to wear masks to class, but only 52% indicated they would social distance elsewhere on campus and 28% admitted that they intended to attend parties on their return. Graduate students were more likely to say they would follow community standards than undergraduates. 

From the initial announcement of the Carolina Roadmap, there was unease among a significant segment of the faculty about the plan to bring back students to the campus. This is not surprising since 20% of the faculty is over age 60 and thus at increased risk for serious COVID-19 disease. A faculty survey revealed that 40% of faculty would prefer on-line instruction only.

Starting in mid-June, members of various fall sports teams returned to campus for individual workouts. On July 7, the UNC Athletic Department announced that 37 members of the football program including players, staff and coaches had tested positive for SARS-CoV-2. With the news of the outbreak among football players, the faculty executive committee met with Guskiewicz and Blouin on July 16. In a wide-ranging discussion, 4 important items surfaced.

1. Jonathan Sauls, Associate Vice Chancellor for Student Affairs, commented that the Community Standards were only enforceable on campus. Fraternities and sororities are located on private property and enforcement of public health orders are the responsibility of the town of Chapel Hill. In addition, Chapel Hill has recently undergone a mini-construction boom of apartment buildings aimed (successfully) at student renters, further increasing congregant living outside of the university’s jurisdiction.
2. When the athletic director was asked how the outbreak occurred among the football players, he reported that they likely were infected at off-campus social events. How staff and coaches became infected was not addressed.
3. Some faculty pushed very hard for universal testing when students returned to campus. There were two arguments given against that approach, which several other campuses across the country were using. First, testing 30,000 students would stress an already limited supply chain and might negatively impact patient care in the UNC Health Care System. Second, there was a risk that the data might be misinterpreted, increasing the risk of transmission. Clearly, those testing positive would be quarantined.The more complicated question was how students who tested negative might act. Would they have a false sense of security and become lax with public health activities necessary to blunt the spread of the virus? Furthermore, what would be done with students who refused to be tested? Would they be denied access to the campus? If so, how would the blowback, certain to follow, be handled?
4. Perhaps most telling, was Guskiewicz’s comment that the Board of Governors of the 16 campus UNC system had mandated that all campuses would begin the fall semester with in-person instruction and only if public health conditions warranted, could the UNC-Chapel Hill use an “off ramp” to digital instruction. The threshold for exercising the off ramp was not defined during the discussion. 

On July 29, Quintana Stewart, the Orange County Health Director sent a letter to Guskiewicz outlining the then-current COVID-19 situation, and sharing concerns about off-campus social gatherings at fraternities and sororities, lack of student cooperation with contact tracing and local testing capacity and turn-around time. She made 2 recommendations:

1. Only those with “true housing needs” should be allowed to live in on-campus housing.
2. The university should consider using only virtual instruction for the fall semester. Failing that, use virtual instruction for the first 5 weeks and then reassess.

In the penultimate paragraph of her letter, Stewart shared this prescient thought: “The data trends over the past couple weeks seem optimistic, however we’ve seen this all change drastically in a short period of time when we move too quickly to reopen our communities.”

On Aug. 4, the mayors of the 3 towns, Chapel Hill, Carrboro and Hillsborough, where the vast majority of UNC-Chapel Hill students live, and the Chair of the Orange County Board of Commissioners shared their concerns with Guskiewicz about the spread of COVID-19 as the students returned. They had several requests, but 2 stood out: 

1. The university should enforce Community Standards “off campus,” with specific consequences for those who did not comply. 
2. Stewart’s recommendations should be followed.

By Aug. 4, the influx of students was in full swing. As mandated by the University System’s Board of Governors, at least some classes were scheduled to begin in person, although many faculty had opted for virtual instruction as their departments allowed. By the start of classes on Aug. 10, 5,800 students were living in campus housing. Although dorms were at less than 60% of typical capacity, some students had roommates. News reports showed large off-campus social gatherings in the week leading up to the start of classes. On the day classes began, only 1 student tested positive for COVID-19. However, during the first week of classes, clusters of COVID-19 cases were reported in campus dorms and in off-campus fraternities and sororities. On Monday, Aug. 17, faced with a worsening situation, Guskiewicz suspended on-campus instruction. A few hours before that decision, Barbara Rimer, the Dean of the UNC School of Public Health, wrote a thoughtful blog piece explaining how the decision to re-open the campus was made.  She concluded: “We have tried to make this work, but it is not working.” 

As of this writing, there have been 13 clusters of COVID-19 at UNC-Chapel Hill, with hundreds of cases reported. The number of cases in Orange County stood at 1,426 on move-in day, Aug. 3. As of Sept. 4, there were 2,371 cases — a 66% increase. Not surprisingly, 47% of Orange County cases were in 18-24 year olds versus 16% statewide. 

There has been much vilification of the individuals involved in the decision to open the campus. Students, in particular, have been vociferous in their condemnation of the university and the university system. 

Although it is easy to be critical in hindsight, there were clearly warning signs that on campus instruction would not be safe for the fall semester.

1. When the roadmap was being developed in May, the daily average number of cases in North Carolina was between 700-800. Because of the aggressive nature of the state’s COVID-19 response, it was assumed that the curve would remain flat. However, by Aug. 3, when students returned, daily case numbers had more than doubled to approximately 1,700. Disease activity in North Carolina had been steadily increasing for 2 months when classes began, but the decision to reopen the campus, based on May numbers and trends, was not revisited.
2. The county health director gave a clear warning that there were very serious public health concerns around student behavior and access to testing.  
3. The mayors and county commissioners shared concerns about the lack of consequences for students who were not complying with the Community Standards.
4. A large segment (28%) of the student body in the June survey said they would consider attending social gatherings on returning to campus. That was clearly the case based on reports that Chapel Hill Police were called to 11 large gatherings in the week leading up to classes. 

Since the UNC-Chapel Hill decision to go to virtual instruction, 2 other large UNC system schools, North Carolina State and East Carolina University, have had significant COVID-19 outbreaks linked to off-campus student gatherings. These institutions have opted for virtual instruction. It is likely that other campuses within the UNC system and across the nation will eventually follow suit. 

Colleges and universities throughout the country have watched the UNC-Chapel Hill experiment carefully. What can they take away from it?

1. They will need to make decisions based on current disease activity in regions from which they draw their student body. Institutions with geographically diverse student bodies may opt for virtual instruction because of the potential danger inherent in bringing individuals from diverse locales to campus.
2. For those colleges and universities that use testing as a gate-keeping mechanism, how testing is best accomplished to insure the safety of the campus community needs to be determined. Like the UNC experience, this too will be an experiment. Understanding these data may guide colleges and universities in the future. In particular, the use of rapid antigen testing may prove to be a helpful tool in identifying infectious individuals. However, there still are many unknowns about how best to deploy antigen tests, which are generally less sensitive than PCR and similar tests. Similarly, pool testing may be a useful approach for screening all students when they first arrive on campus but this testing will only be helpful if infection rates are low. Again, local COVID-19 epidemiology will impact decisions to use pool testing. 
3. Some college students may not act responsibly and may engage in risky behaviors, endangering themselves and others. Although personal responsibility is preferred, consequences of unwanted behaviors may be necessary.
4. Campuses that are part of a multi-campus system such as UNC need autonomy to determine the mode of instruction that will be used. At the time UNC-Chapel Hill resumed on-campus instruction, COVID-19 cases were increasing in North Carolina, especially among those of college age. COVID-19 cases accelerated when students returned to Chapel Hill, as public health and governmental officials, faculty and students all feared. Too many important stakeholders’ voices appear to have been unheard. Flexibility based on disease epidemiology is essential. 

As someone who has devoted much of my professional life to teaching students at UNC-Chapel Hill, watching what has happened to the UNC community and the community of Chapel Hill and Carrboro this month has been painful. But a clear reckoning is needed. The questions we must ask are, where did we go wrong and how can we do better?