Episode 6: Balancing Health and Energy During COVID-19

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John Mandyck (JM): Good morning, everybody. Welcome to Urban Green Live. I'm your host, John Mandyck; I'm the CEO of Urban Green, and I'm coming to you from the Urban Green Studio in Lower Manhattan. This is a program series where I'll be interviewing global experts on important sustainability issues of the day, and you get to participate, too, because we're going to have live Q&A in just a little bit. Today, we're going to take a look at a topic that's asked about over and over again in the Buildings Community, and that is, how do we maximize for both health and energy efficiency, especially in the age of COVID.


So to explore that topic, we have our very first return guest on Urban Green Live. It's Dr. Joe Allen. Joe, say hello!

Joe Allen (JA): Hi everybody, thanks, John! 

JM: Joe is the assistant professor at the Harvard T.H. Chan School of Public Health. And he's the director of the Harvard Healthy Buildings Program. Joe has emerged as a global voice of scientific reason for the Coronavirus with daily media appearances. When he's done with us, he's got about four more media interviews today. You've probably seen them numerous times. He's been on CNN, CBS News, NBC, Nightly News, or in The Wall Street Journal, New York Times, and more. He is the go-to scientific source for everything buildings related to the Coronavirus, and we're really grateful that he is spending an hour with us here at Urban green. So Joe, welcome back to Urban Green Live. 

JA: It's good to be back with you, John, thanks.


JM: Hey, Joe, the first time you joined us in April, those who remember, you did it from your car because it was the only quiet place, and it looks like you've moved into a home studio. You're moving up.


JA: Yeah, moving up in the world. Yeah, the early days when, you know, no one knew what was going on. Certainly, no one was set up for everybody being home, and like everybody else, I had kids working and doing school at home, and that was the only quiet place I could find to do media interviews, to actually do work, and I was teaching my class from the car. So, happy to be in a room now. 

JM: It looks great. So Joe, Let's get right into it. I love your assessment of where America stands right now with the Coronavirus. Are we halfway through this crisis? More? Is the end in sight? Can do even know? Can we tell? What are your thoughts?


JA: Yeah. So, I mean, that's the trillion-dollar question, and you've seen ranges of estimates by different experts, and a lot of it depends on what your definition, I think, of "out of it" is. Right. So, when Fauci says, "We won't be back to normal to the end of 2021," He's talking normal-normal. No mask. No restrictions, back to where we were like January 2020. I'm more optimistic on the front that I think we can get back to some re-opening and some semblance of normalcy.


I wouldn't call it quite normal, through what we're doing already, and some advancements that are coming. So specifically, you know, I think it's really clear that non-pharmaceutical interventions are working and allowing us to have a bit more freedom in what we do. With care, mean non-pharmaceutical venture, it's meeting the things we've been talking about for a long time now.


Hand-washing, universal masking. We'll talk a lot about buildings, what buildings need to be doing, so these kinds of universal precautions at this point. We have, we can talk a lot about how the testing landscape is poised to change, and this is something that's really worth diving into a bit, and we can go there. We also have new therapeutics coming online, and the endgame is the vaccine, right. And that's when you essentially, you know, we can we'll be able to free up a lot more but in terms of normalcy, you know, it doesn't mean we're fully closed down till then. It just means we're going to have to be until the end of 2021. We just need to have a lot of precautions in place.


I don't see us getting out of this anytime the next couple of months, and I'd say that I like most people are really quite uncertain about what November, December, and the winter brings. There are many epidemiologists who are predicting it can be quite bad. We've seen the models out of, out of Oregon, out of Washington, and there are others who are a bit more optimistic because of these behavioral changes plus advances in the testing.


So, of course, like it's been since the beginning, just highly uncertain, which is unsatisfying. 

JM: Yeah, so, this is the side benefit here. Do we finally have a systematic way to combat the normal flow? I mean, it's everybody washing their hands and wearing masks. There's been this concern about flu season and what the impact is, but, you know, is this a way to beat this common flu with the common sense approach that people would take for the Coronavirus? 

JA: Yeah, I mean, we're already seeing that, right, we saw this in the Southern Hemisphere, where the flu season was tamped down - and tamped down is too light of a description - because of these non-pharmaceutical interventions, right? We're, no matter what, however imperfect, the fact that people are wearing masks, we're doing this (virtual webinar), right? We're not together, people are distancing, when you're at the grocery store there's Plexiglas. Like, all these things are having an impact. And there are some people who are fully locked down, of course. There are many people who have to be working right now, and aren't locked down.


But they're having an impact, and I'm more optimistic on that front, that this flu season, that a lot of these interventions, I hope, well, two things will really help here. One is that these interventions will help drive down flu transmission. Two is that the new rapid testing that's coming online will help us differentiate between flu and COVID. You can imagine we don't have that coming into November. And every sniffle of a kid in a school or an office worker shuts down the floor. We're going to need to be able to, and we are going to be able to, differentiate. That's key. Absolutely. The third thing I'll say, it's critically important, is everyone needs to get their flu shot this year, right? Normally that's good public health advice every year, but really. You need to get your flu shot.


We all need to do our part here to help tamp down even further this influenza, to take the pressure off our health care system, and two, to be able to disentangle these impacts. So just a reminder, yeah, make sure it's not just the mask-wearing and that you get your flu shot.


JM: You've published about 15 op-eds on the Coronavirus topic. One was "6 Reasons for Optimism". Tell me, Joe, why should we be optimistic? 

JA: You know, so that came out in July in the Washington Post, and at a time, we saw cases rising in a lot of parts of the US. There wasn't a lot of signs of optimism. But there were some, and I'll tell you the big-picture reason is this. This pandemic is the first time nearly every scientist in the world is focused on the same problem. So, it is inevitable that breakthroughs will happen. And the breakthroughs that you're seeing on the front page news, you know, we all see these - on vaccines, the data look good.


But there are things happening below the fold, right, that the scientific community are producing these wins that are helping us get through this. And one of those six reasons for optimism, you know, I talked about? One, which is interesting, is that we're recognizing airborne transmission is happening. So why is that a sign of optimism? Well, we've been shouting for that since February, and it finally means that maybe other people who haven't been paying close attention will start to put in some of these controls. So that's a big 1. Two, I'm not gonna go through all six, but I'll mention another one that's below the fold that maybe people aren't aware of. There's a series of studies now showing a really consistent result - 20 to 50% of us have antibodies that respond to the novel Coronavirus, 20 to 50% of people who never were exposed to the novel Coronavirus. So I could say that a little bit better. It looks like our past exposure to other common cold coronaviruses is giving our immune system some memory, and while it's not a perfect match for the novel Coronavirus, these residual memory T-cell response is able to still recognize this as foreign and confer some benefit. How much? We don't know. But it's not an insignificant amount of the population that has this. So that is another sign for optimism. The third, I don't know if you want to go deep into testing, but I think we should, is the improvements in rapid antigen testing. So I'll let you decide if you really want to dive in there, but that's something that's definitely worth - gives me some optimism here.


JM: Great. Let's go back to the antibodies. So, there's, you know, this has been bantered about quite a bit. And frankly, I don't know where science is falling on it right now, but is there a view that if you've had the Coronavirus, that you have the antibodies that will prevent you from getting it again? Or don't we know yet?


JA: Yeah, so it's, I'd say it's an open question, but there are good signs. It looked, earlier on, we were really quite unsure if someone could be re-infected. And we, the scientists were saying - talk about unsatisfying - We kept saying, well, you have some protection for some amount of time. No one knew what level of protection or for how long. It looks like, now, that there is some protection, re-infection is really rare, if happening. We'll know more about that in the coming months, just how rare that is. But it looks like two things are happening. One is the antibody response, and two is that your body has this memory T-cell response. So you're more likely that, even if you did get it the second time, if you catch it, your body is responding, you've already - it's already seen the virus once.


So I think the news there is better than it was in the spring when we really weren't quite sure. I'd say by now, right? How many millions of people have been infected? If re-infection was happening a lot and we're 8 or 9 months into this pandemic already, we would see a lot of re-infection by this point. And because we're not, it's a good sign. It means that it's not - if it's happening, it's not common. Or if it's happening, that people have - their immune system is responding sufficiently (enough) that it's hidden and we're not really seeing it in the numbers that we would be, so I think that's a good sign. Yeah, yeah. 

JM: So let's talk about testing - where, where do you think testing is today, and where does it need to go?


JA: Yeah, so we're on the verge of, I think, a fundamental shift in how we view testing. We've been talking about this and my colleagues and others through the summer that there needs to be a paradigm shift in testing, and it's happening. So let me just quickly talking about PCR testing that everybody knows about, right. And think about the time course of your infection. You get infected, the virus builds up in your body, and then you're really infectious. You can infect others two days before symptoms, and 5 to 7 after symptoms. And then it tails off, right. So, PCR is the gold standard - it's going to detect you (when virus levels are) down low, it's gonna detect you through peak infectivity, but it's going to detecting for a long time afterwards.


In fact, that's a downside the PCR, you will be way past the point of infectivity, and it's still going to say, John, you're positive, which means you quarantine, close contacts quarantine, it's a problem. The second problem with PCR is that it's a lab-based test, it has to go to the lab, and you've seen the slow turnaround times - two days, four days, seven days, ten days. It's not actionable data. So there's a new set of testing. It has a couple - people are calling it a couple of different names. So you'll probably hear it called lateral flow, Antigen test, some people are calling it infectivity test, Quick test, rapid test. And it detects antigens.


Here's the difference - think about you get infected, you're at peak infectivity. These new tests detect you at peak infectivity or contagiousness, and they don't detect you on the long tail. So that's good. Two, they're rapid - 15 minutes. Three, they're point-of-care, meaning, you could do it at home, you could think of this as a home pregnancy test, but for COVID, and it's saliva-based. And they're cheap. And if we do these at scale, we can get down to the cost to $1, $5. It could be as low as $1 per test. And so it doesn't - it's not a stretch to say, well, this could really help, not only do people feel more comfortable going out and about, were companies deploying these, but two, it helps to slow the spread, because now you're not waiting for PCR tests, where nobody knows if they have it. You can find out that day in 15 minutes. Or you go to the doctor's office, and you're not sure if your kid has flu or something else. And this test says, you know what? It's COVID, or it's not, or it's something else, or it's the sniffles. So that changes the paradigm.


The good news here is that this technology has existed. It's not - you know, I'm not - It's not snake oil here. It's backed up by good science. There are many platforms already available. It's been held up by the FDA until a couple of weeks ago. So just a couple of weeks ago, FDA released or approved the use of Abbott's new device, the saliva-based, rapid point-of-care test. And this scales - Abbott is saying they'll have 50 million tests this month, 100 million tests by November, and other platforms are right behind it. So the door's been opened now for FDA to say, Yeah, you know what? These antigen tests are good, at least on this one platform. It's - and others are ready to go, where it's a saliva-based, at home, rapid, low-cost test.


JM: That's good news. We'll have to look for those. Let's switch to talk about buildings. Now, a big challenge, as we all know, is to balance energy from ventilation with the health benefits that we get from that ventilation. We've talked about this before, Joe - is just really an either-or problem? Is, I mean, is - can we finally find a way to have both?


JA: Yeah, we can. I, you know, it's been presented as either-or for a long time. I hated that presentation because it felt like it's, it's binary, and it's not - nothing's quite binary. And I think one of the problems is we don't think about this holistically. We tend to think about it as binaries, in buckets, right? So, of course, higher ventilation. Well, maybe we should talk first about why these benefits exist. And I think there's one other component of the higher ventilation and health question right now, which is the risk calculus is different with COVID, right? Before, and I've been a big proponent of this for a long time, you and I have talked about this for years. There's a lot of benefits to more fresh air coming into the building, clearly, we've talked about these forever. Now with COVID, it becomes well - it's not just that I won't have a headache, someone in my building won't have a headache, or they'll perform better on these cognitive tests.


No, we're talking about - we're in the middle of a pandemic. And we're - and the economy, it's totally shut down, and buildings are entirely shut down. So, in my view, we have to - it's a different conversation right now, anyway, to say, Well, what do we have to- we have to throw everything we can at this current problem, not ignoring climate and the other energy conservation. 


But we're in a massive, unprecedented public health crisis across several domains. It's a health crisis, it's a social crisis, and it's an economic crisis, it's existential, and I don't think I'm exaggerating that, you know - how many businesses are just closed? Think about New York City. How many small businesses are closed? How many of the small businesses depend on the large businesses being open, that people are coming back? And there's anecdotes of people leaving the city? And, you know, alright, so, We have all that, So, it's an economic crisis, as a public health crisis, and I think buildings have a key role. How we operate buildings has a key role to keeping people safe and being able to restart this economic engine that relies on us being in buildings.


JM: So, if it's for the building managers watching, what are the factors that you think they should be considering? I mean, can you frame it for us? 

JA: You mean, in terms of risks from COVID more broadly, or just this energy health conversation? 

JM: Both, together, I mean, I think it's hard to separate both, but let's start with, you know, what's your recommendation to for re-occupancy of buildings and steps you can take there, and then let's tackle the energy question, too.


JA: OK, yeah, yeah, so this is critically important because certainly, the buildings can play a role, but it's a larger conversation of risk reduction, and the strategy we've been advocating - I wrote about this in Harvard Business Review back in April - is to use the hierarchy of controls. I forget if we talked about this in our first - I can't remember when our first podcast - 

JM: In April. 

JA: It was right about then, and so maybe we did mention it.


But there's no one strategy in and of itself that sufficient to reduce risks. So, it's a layered defense. You layer these defenses on top of each other: screenings, self-testing, stay at home when sick. At least, as we think about - the hierarchy of controls comes from the field of worker health and safety. There's just five parts: eliminate the hazard, prioritize work from home, where you can, but, we can't restart the economy that way. Or, not all aspects of it. Two, substitution is number two in the hierarchy, and that's- you want to bring back core people first. I think that makes sense, who has to be physically present in your buildings.


Three, engineering controls, these are healthy building strategies: better ventilation, better filtration. Four, administrative controls, the densification of your space, increasing physical distance, managing flow as the people in the elevators. Then five is PPE, and in this case it's universal masking. By the way, this is the same approach that's used for toxic, chemical, industrial manufacturing sites. So here, all that is applied to COVID. So it has five parts. I think that's nice, because I've been talking to a lot of building owners, and encouraging them, especially when I talked to facilities managers, to say, we should be reminding everybody all the time that it's not just the third one, the buildings, right.


That ventilation, in of itself is not going to stop this. It's part of, a key part of, a larger holistic risk reduction strategy, that we know actually works, and I'll just say, why? How do we know this works? Look what's happening in hospitals, where we've driven down the risks to health care workers, which was outrageously high early. Hospitals: high-risk environment, lots of people shedding the virus. What are they doing? Hand-washing, masking, and, you have to pull this one out of them, but when you remind them, they remember the third one, their buildings. Hospitals do a good job with ventilation, filtration. Infectious disease doctors say, Oh, yeah, that one too, they'll say masking and hand-washing. They forget that third one sometimes.


What aren't they doing? They can't physical distance. So we know we can drive down risks with these kinds of basic control measures, we see it happening. And the counter-factual, the opposite of that, is when we don't do those things, we see outbreaks. We see it in a bus. We see it in camps. We see it in schools. We see it in a restaurant. We see it on the cruise ship. What do they have in common? It's not necessarily the specific place that matters, but what they're doing. A lot of people, no mask, no ventilation. And so we're seeing the positive and the negative of this, and we put it all together. We know we can control risk indoors. That's the holistic picture of risk reduction.


JM: So, what is your recommendation on ventilation?


JA: So priority - so first, there's always a solution, I think, especially in dealing with the schools conversation right now, where people seem to be getting stuck- "I can't do it. I have an old building. I have this system that can't do X". There's always something you can do. Let's start with that. Two, we'd like to prioritize in this manner: One, higher ventilation rates, going above the minimum ventilation standards, which are not set, as you well know, for infectious disease control. Two, better filtration on the recirculated air, so upgrade to Merv 13 filters. Three, supplementing that, if necessary, with portable air cleaners, with HEPA filtration or supplemental ventilation. And four, if and only if this isn't working for you, think about more advanced control strategies, like people sometimes jump right away to Ultra Violet. I'd say, let's exhausts the tried and true, not that ultraviolet's not tried and true, but let's say more practical, lower cost, easier to implement and maintain strategies and work through that list to create these indoor environments with reduced risk. The number we put out there is 30 CFM per person, for the outdoor air ventilation rate.


And I tell you, it's frustrating for me that we've put out a number, and I haven't seen others do this. You won't see a number from CDC, except for health care settings. You won't see this from WHO. You won't see it for ASHRAE. We were dealing with schools in July, trying to get them ready, New York City schools, too. And people are saying, Well, what's the target? You can't find one.


No one was setting a target. And so you can't tell people, "improve your ventilation filtration." Well, what about- what's the target? And then when saying we don't have a target- we have to give a target. We think that's an evidenced-based target, based on what we know now, with the full caveat that we don't know the dose-response for this virus. We don't know it. When we do figure this out, if it's soon, or if it's many months from now, that can shift our recommendations, it should shift our recommendations for control strategies across the board, including ventilation.


JM: So the 30 CFM, you know, building owners will be concerned about the energy that's needed to do that. Of course, that can be offset through other mechanisms in the building by reducing energy someplace else, offsetting it, demand control ventilation, there's other strategies. But let's just stay with just 30 CFM. For infectious disease, do you recommend the 30 CFM until there's a vaccine? Or is this like 30 CFM forever?


JA: So a couple of things- I'd say right now, a couple of points: One, the 30 CFM per person, a lot of buildings are probably doing that anyway just at their current air delivery because they are de-densified. Sometimes by choice, saying, hey, we're Mac, we're limiting our occupancy to 25%. But at least the groups I talk to and what I'm seeing nationally, is that, even when occupancy is allowed to be at 25%, you're seeing Census counts below 10%. So it turns out right now, I think there's probably a lot of buildings that aren't paying any kind of penalty because they're not occupied, or they're, they're lightly occupied. And I don't see that changing. A lot of the bigger companies are able to keep a lot of their staff working from home through this.


So you get the benefit there right now, right? It's not, it's not like you're getting killed on energy right now, because you're benefiting from the de-densification. In terms of what should go forward? I do think it should be 30 CFM per person going forward. And here's why. And we lay this out in my book, and I wrote it with John McCumber at Harvard Business School. We talk about this. And again, we felt like people weren't talking about what the number should be. You see some rating system, say, well, 20, 30% over the minimum. I'm not sure where the 30% number came from. I think it's good to go over the minimum standard, but where did that get derived from? There's a couple of things we know. The current ASHRAE Standard for ventilation, we've talked about this a million times, is the standard for acceptable indoor air quality? It is a minimum, is a minimum.


It's odor control and the basics, the basics of indoor air quality. If you look at the scientific literature, decades worth of this, it shows that these minimum standards- well say, flip it the other way- when we exceed these minimum standards, when we bring in more outdoor air, clean, outdoor air, there are benefits across many domains, one being infectious disease transmission. That's obviously relevant right now. And, well, is always relevant, really. Relevant from an economic standpoint, for businesses, we can have the economic conversation in a second. Better cognitive function, we've talked about the cognitive effect studies, and others, that's not the only study out there. There are dozens showing better cognitive performance or better test-taking, better math performance, fewer headaches, less eye irritation, lower sick buildings, and on and on.


And so, to me, it never quite made sense that we have a minimum target, OK, ASHRAE defined that, that's fine. ASHRAE is explicit that it's a minimum target. That's not really their fault. It's just that, then we've designed to this minimum target. It's led to problems in our buildings since the eighties, late seventies when we did. And if you look at that same body of evidence, we feel comfortable that this 30 CFM per person target is supported by all of that science for a building that not just tries to limit, you know, VOC exposure, but actually leads to human health and performance benefits. Yeah, and there's a business proposition there too, right.


JM: So, we're gonna open it up to audience questions in just a bit, so I'll remind the audience, type your questions in, and we'll get to those in just a minute. So, Joe, what do you think are now the long term expectations for healthy buildings going forward generally?


JA: This landscape has shifted, and everybody, I'm sure, on this call has seen it. And if you haven't, then, you know, pay attention because the game has changed. I'd say, back in the early part of the year, January, February, I could name, everybody was talking about healthy buildings, every company, every person, every scientist, right? Now, everybody is, really everybody. You've seen: major Fortune 100 companies stand-up healthy building divisions, multiple companies doing that. You've seen commercial, landlords set up healthy building operations. You've seen this in biotech, finance, the arts. Everybody's talking about it. You see all sorts of new products coming on the market around healthy buildings. We see people talking about renegotiating leases based on healthy buildings. So, this market has shifted, which is a good thing.


And I think, that the shift, that, maybe, some people aren't quite seeing, or maybe, not everybody just yet, is that it's not just COVID. So, of course, right now, everyone's focused on COVID. You have a COVID plan. Every company has this in place, now. But the expectations are different. And the good companies are already starting to say, Well, what else matters for health? Water quality, right? That's not related to COVID, but people are talking about that. Lighting, biophilic design, you know, the usual cast of characters here. So, there's a fundamental shift in the market. And, it makes sense for why, I mean, look at the- Look at the public sentiment right now on return to work, return to anything. A lot of people aren't going to do anything until that vaccine comes, and it's widespread. So a lot of it is saying, Well, how are we going to get people back in?


How do we differentiate, and what is a downturn market? All things considered equal, if I'm a business owner, I've got to choose between your building and the building next to it. Same area, one building has put in these healthy building strategies, which one am I going to take? Knowing my employees won't go back if it's not a healthy building, right? It becomes a clear choice, so the market has shifted just really abruptly, it took off. 


JM: So you mentioned water, which I think is an interesting analogy because the water that flows to a building has to meet a standard. It's tested, you know, people, you know, don't any more fear drinking water from a tap, because they know that behind the scenes, there are regulations and testing to make sure it comes to you, in the right way, it comes to you healthy. We don't have the same for air.


How do we get over that? I mean, is there a role here for standards? We talked about that, you know, nobody, you've put out there, 30 CFM, nobody else has. But, you know, is there a broader role for air? There's outdoor air quality standards, but not indoor air quality standards, So, you know, what's your view on that?


JA: Yeah, we need it. We need it. The ones that we have for indoor are limited. They're like OSHA occupational exposure limits. So it's like so you don't die from metal exposure in your office, which isn't going to happen anyway in a commercial office space, so they're not really practical. OSHA admits, and its own admission that says they're not updated and actually don't provide a safe environment.


Couple of other regulations around things like Radon, and it's really sporadic. And, and sparse and it's not really tied to, let's say, optimal health benchmarks, it's more of disease avoidance strategies, right? So we can have that, OK. Look, at your meeting, the OSHA Occupational Exposure limits, and IOSH recommended exposure limits, great, you know, the disease avoidance strategies. What about optimal performance? Those are not set for optimal performance by any means. So there's a big need for this, to define what is the targets? Like we talked about for ventilation. But the same thing for, you know, there are targets for water quality. It's the basics, though, I have to say.


And we don't have any for many of these other parameters, right? VOC, semi-volatile compounds, These newer, you know, the newer semi-volatile compounds that we know a little bit less about. What we know about is, is concerning, And we don't really have targets for this. But we should, I think, and there are people working on it, right? My team is certainly working on it, academic labs are working on it. There are commercial offerings. Non-profits are putting some standards out, people are trying to define it. I think that's where we are in this moment. It's a key, it's a pivotal moment.


This, as you know, as you mentioned, well healthy buildings are- as this is happening, people are starting to ask them, well, who defines that? And will we have health-washing like we had greenwashing? And that's a problem, if we cut corners on health, not that it's good to cut corners on green, but if you screwed up your energy count for your office, OK, not good, but nobody's dying.


If you do that in a building, you screwed that up, and you cut a corner around COVID or something equally serious, that's a problem. It's a different risk basis that goes into that. So, the short answer is, yeah, we need some standards for the indoor environment that are beyond disease avoidance standards and work towards health promotion standards.


JM: So, get your questions in, and we'll get to them in just a minute. John, just talk a little bit about schools. I know you've done a lot on this. I know you're very passionate on it. You know, it's important. Schools for school's sake, but you mentioned re-opening the economy. It's important for parents to get back to work that, you know, schools are safe and stable as well. So it's integral to everything we've been talking about. What should schools be doing? I mean, what's your thinking there?


JA: Yes, I'm glad you framed it that way. It's absolutely correct, you know, we're not really going to restart- We're talking about buildings, commercial real estate, but we're not going to restart the economy when schools are closed. First, I think we have a responsibility, a moral responsibility, as a society, to open schools first and get kids back, and it is a nightmare what's happening. And let me explain, not just my own situation where I have three kids doing school in this house on the other side of these walls.


Let's take- Let's just talk about schools and get away from the reductionist risk in the classroom, which I'll get to and address. But let's take a wider lens on exposure risk, right? When kids are out of school, they're at higher risk for abuse, exploitation, violence, and neglect. Over 30 million kids in this country rely on schools for food. Kids who are not at school are less active, less social.


We have virtual dropouts on the order of tens of thousands. In Boston, 10,000 high school students didn't show up in the month of May. In Philadelphia, half of the elementary school kids logged in. This is a problem- we're sitting on, we're talking about cases here, we're going to talk about the public health problem of schools closed for years, I'm not exaggerating. But now let's talk about risk in the building and how we can actually control it, because that's the other part of the conversation. Two conditions precedent.


One, low community spread. So I have, with other colleagues at Harvard, we put out guidance for when these- when you meet these conditions, you can open safely. First condition precedent, and I can point you to the guidance document for anybody who's interested. Two, it can't be schools as usual. You have to put in those, that hierarchy of controls framework.


Universal masking, hand washing, ventilation, and filtration are critical in schools because they're chronically under-ventilated. Do you do those things? We know we can drive down risk. We get the benefit of the reduced risks to kids, that the virus has not spared us in any ways. But that is one, not that kids can't get sick or suffer severe consequences. But compared to adults, they're much less likely to get this, 2 to 3 times less likely.


If they do get it, they're much less likely to die. An infection fatality rate on the order of three in 100,000. That's 10 to the minus five risk. It jumps to the percent level as you get older, which is scary. We've all seen these differences by age. Three, it looks like they're less likely to transmit to others. So, you get to some things that are happening in schools. But taking that wide lens on what this means to get kids back in schools, versus the risk of keeping them out. We know we can keep them safe.


These controls don't have to cost a lot of money, and we can't have, you know, keeping them out is widening gaps that exist in our society already. Essential workers have to go to work, who's watching the kids? I have high-speed internet and computers for my kids; over 10 million kids don't have high-speed internet in this country. You've seen the pictures of kids in a Taco Bell parking lot connecting to the Wi-Fi to go to school.


So we have some real- and I tell you, the other one I wrote about this in June was that the, it's a disproportionate burden on women. So we have women dropping out of the workforce at higher rates than men.


So it's widening all these gaps that existed in society already. It has to be an absolute national priority to get kids back in school. I know we didn't come to talk about schools, but it is perfectly intertwined with what's going to happen this winter, and coming out of this. It's central to what happens about us getting back to work and re-opening our buildings.


It's central to the conversation of disease dynamics and spread. So it's all wrapped up. And so you know, I know we tend to think about schools or commercial real estate or air travel. It is all linked, and we have to start treating this as the schools, in particular, as a national emergency that it really is.


JM: Great, thank you, Joe. Kaitlyn, I know we have questions coming in, why don't we open it up to audience questions? 

KL: Sure, we have a ton of questions coming in. So thank you to everybody, we're going to try to get through as many as we can here. Our first question is from Yuen: "Hi Joe. Thanks for this discussion. In the context of better indoor air quality and ventilation, the solutions that are proposed, while on a range of affordability, still represent significant cost that some communities cannot afford.


Given that low to moderate-income communities feel the negative effects of both energy transition and COVID-19 disproportionately, what are some insights you can share for these communities to balance health and energy moving forwards?"


JA: I loved that, thanks. I love that that's the first question because this is my biggest concern with the healthy buildings movement. If it's a movement for, you know, the shiny new building in Midtown New York or London and not a movement for everybody, then it's a failed movement. And so, we absolutely have to put in these programs and policies in place, to drive these solutions all the way upstream, and not just to the commercial real estate market, all the way through residential, and including affordable housing.


You talk to all the- I talk to physicians at Boston Children's Hospital, who talk about this. They're treating the same kids over and over and over again every time they come back to the door with no effort to move that upstream. So, the idea, again, that this is a cost is true, only if it's a narrow lens on the costs and what it takes to implement these healthier building strategies. Take affordable housing. We took a holistic perspective- we're saving money, a lot of it.


If we drive investment into better housing around these healthy building strategies, you're preventing all those downstream health effects, or limiting them, or mitigating them. So, it's absolutely critical that we think about not just, you know, healthy buildings in this context of let's say downtown New York City and the high rise of Midtown, but a wider lens around equity too. And I agree. The other part about healthy building strategies- they're not expensive.


They're expensive, like I said, when we narrow it down a bit, and just think about the cost, some of them have a higher cost, some of them don't.


But it's when you if you factor in the health benefits, population-wide individual benefits, or even benefits to the bottom line of the company or organization or the value of the property, residential or otherwise, the benefits far outweigh the costs. I think we have the cost conversation, again, a wider lens is really necessary. That's a really good comment.


KL: Great, and I have a couple of questions here about this 30 CFM per person. Dan asks, "Hospitals have high energy intensity due to increased filtration, high air changes, tight temperature and humidity requirements using in-room air cleaners and pressurization of spaces. If these strategies are applied to schools and offices, how is there not a trade-off between energy and risk mitigation? Schools currently require 10 CFM per person for ventilation. 30 CFM is three times that."


JA: Yeah, so good comment there. So, the key distinction, right? I'm not saying every building should be run like a hospital by any means, right? Context matters. And there you have much higher risk, obviously, for infectious disease transmission, so it's not the case that we have to operate like we do for hospitals. The strategies we're talking about for schools, in particular, are really if- there's a cost to them for sure, higher ventilation rates, but it could be higher ventilation rates just from opening up windows.


Or in the case of the importance of getting kids back to school, it's putting a portable air cleaner with a HEPA filter into every classroom, which is an expense, a couple of hundred dollars. Take that against the cost of keeping kids out of school. And it's a trivial investment actually considering the trillions we pumped into the economy, to pump up the economy, necessarily.


Why haven't we done that, same, to get kids in school? So the cost, at least in the COVID context, yeah, we're not saying every building has to be run, you know, with like, hospital airborne isolation infection rooms have HEPA filters on every, on the exhaust or they're hitting 10, or actually 12 air changes per hour now. So that's not what we're saying for this. There is an energy penalty, there's no way around it, and it's worth the conversation that, again, it's, it's, I'm repeating myself.


But it's, this is the way I think about things, is to take a step back and think about holistic problems and holistic solutions. So obviously, we have to clean up and decarbonize the grid, right? Let's start there. And I know there are different challenges. Certainly, there are different challenges from New York City versus elsewhere. But that's absolutely key. Then can we tackle low hanging fruit in terms of energy efficiency in our buildings? Can we make better decisions on the technologies we're putting in, in the first place?


In other words, running higher ventilation rates while also energy saving through other technologies or approaches to how we ventilate those spaces and designing better in the first place? So it's not this, you know, again, binary, yes, it's energy or health, That's where it always comes down to. It's actually not.


We can take a step back, think holistically, knowing that, of course, of course, we have to keep our eye on the other slow roll, and no longer slow roll crisis in climate, and building a central role, contributing to that through energy consumption and on-site fossil fuel combustion.


KL: Alright. This other question is from Barry: "Have you looked at air changes per hour versus CFM per person based on density as well as occupancy?" 


JA: Sure. Yeah. And actually, for schools, we opted- of course, they're related, and even the CFM per person is a simplification. Because as ASHRAE has it correctly, it's an area and a burst per area per person calculation simplified as a per person based on typical occupant densities. And then air change, of course, ties right into that based on the occupant density and the volume of space, what you're going for there.


And for schools, we actually spent a lot of time on this, on a weekend in July, with some other faculty around the country, and opted to, at least in our guidance documents, have schools target air change per hour instead of per person, CFM per person number. It's a simplification. We like it. It's easier. I think it's more intuitive. Again, we were trying to get guidance. That is not, you know, we're designing schools for the next 30 years. It's how do we get kids back in school in the next 30 days? And, so, there, we say, four air changes per hour is good. Five is excellent, six is ideal. If you're hitting the ASHRAE Minimum Targets, at typical occupant density for schools, you're roughly around three air changes per hour. So it's up the colors- the first 10 CFM per person. Pretty sure, it's 15 CFM per person. It's a point five liters per second per person is the ASHRAE Standard for Classrooms.


So that gets you about three air changes per hour. We like upping that to 4 or 5, and thinking about that from a turnover sense, again, it's intuitive. You're getting every 10 or 12, 15 minutes. You're turning up the volume there in the room. And we'd like it because it's also a nice, easy calculation to say, well, if I have X amount of air coming in from outdoors and recirculating some percentage through a high-efficiency filter, or I'm using a portable air cleaner with a HEPA filter, it's easy to add up those air changes to hit the target.


And we found that schools like having an air change per hour target, something they can shoot for. It's really intuitive, again, say OK, I'm trying to get the five air changes, which combination of approaches will get me there?


KL: This question is from Sheena. "What about air ionization as the technology to help reduce COVID transmission for new construction projects?"


JA: Yeah, I know a lot of people are talking about this and all sorts of new technologies. First, I go back to what I said in this prioritization, I would go with higher ventilation rates, high air filtration, recirculated air, supplemental control strategies, and then these more- advanced may not be the right adjective, but additional, let's call them, control strategies to consider.


Some people think about ionization, some people are going to UVGI, Ultraviolet germicidal radiation. Others are trying some other techniques. But- I think there's a place for some of these technologies in the right context. If you're in a hospital waiting room, your system can't bring in more outdoor air, you can't handle the pressure drop of the better filter, or other reasons, there's a lot of people who are potentially infectious, and you want to do something. So I think there's a role, it's context-dependent.


With these newer technologies, it's not that that's new, but let's say newer applied technologies, We have to think about the evidence base that they work and not just evidenced-based in a laboratory, where a lot of these things work in a lab. How do they work in applications? Is there data that you can be shown from a manufacturer that says this reduces risk? This is effective against SARS-COVID2.


Of course, it's going to matter the application, the flow of air. How many, in this case, how many ions. And with some of these, we have to be really careful that we don't generate unintended hazards. In the case of ionization, you can generate ozone. Ozone is a respiratory irritant. You can generate ultrafine particles, another respiratory irritant. You can generate formaldehyde, another respiratory irritant.


So for me, it's always, well, can we do these other control measures where the evidence base is deep, both laboratory-based and field-based, they're cheaper, easier to maintain and operate. And there are no known- there's not a potential for a secondary effect. So for me, it would require a much deeper evidence base before I gave a recommendation to put in- remember that fourth control strategy- one of these newer technologies before I exhausted the other approaches. 

M: So, John, let me jump in and carry on a little bit about filtration.


Is there for buildings that can't bring in additional outdoor air because their systems are maxed? Or if the energy penalty is too high and it's- the energy analysis shows, it's easier to filter versus, you know- Is there a trade-off here? I mean, can you do filtration and not ventilation, the increased ventilation, or do you need to do them both together? 

JA: Yes, I know they're all- You're doing the same thing. Right, I think the way to think about it, it's like, total clean air, and this case, clean, meaning, you know, a viral sense, right? So outdoor air can be dirty- Look what's happening on the West Coast, right? So, they're bringing more outdoor air is a problem right now, Unless you're filtering that air to a high degree before it comes in, that case, you would want to decrease the amount of outdoor coming in and increase filtration. So they're working together, and it's gonna matter about the volumetric flow of clean air being, you know, two- couple mechanisms for viral removal.


One is its deposition. Over time, some particles will settle out. Two dilution, three, you clean the air through filtration, or four, it's absorbed in the lungs, deposited in the lungs. So, of course, we're trying to stop that from happening. But if you model this, if you do an indoor air quality model, you have to account for all four factors, including lung deposition, which tells you stuff.


And so these two are working similarly. So you can get there with a high degree of filtration. In fact, that's the idea of a portable air cleaner in every classroom, or I know some organizations are wheeling in industrial grade, portable HEPA Systems give you 500, 600 CFM of air through a HEPA filter, so that's clean air would count towards your air changes. So there are other strategies for sure. In fact, this is what people should be doing on the West Coast.


KL: Alright, a question here, "What kind of international information sharing is going on that can help move solutions forward for vaccines and other treatments?"


JA: Yeah, so the question is a good one, even before the vaccine and treatment thing came in because, I tell you, I don't know if the public always sees this, but the scientific machine internationally is roaring. I have, myself, have established, I came account could probably over 50 new scientific collaborations around the country, around the world, people I've never worked with. Because everyone is open right now to finding solutions? Right?


Normally, like any other industry, we- not compete, but everyone wants to have the first new paper out- everyone's, like, I hear you're good at this. I'm good at this, Let's get together and solve this problem fast, and this is happening across genetics, epigenetics, vaccines, therapeutics, indoor air quality, building sciences, you name it, medical communities doing the same. So, you should be heartened, I'd say, you know, and from a US context, our investment in the basic sciences is paying dividends. And this is happening.


It's actually- as we come out of this, I hope we double down on, on our investment, because some things that we invest in, that we, I think we tend to think of, as a public, well, what's the utility of that science? All of a sudden, these new techniques and biostatistics are really relevant, that we didn't think were going to be relevant to understanding vaccine trials. Or this new study that came out yesterday for my colleague who studies cell death, who then says, you know, I'm gonna apply that to these receptors in kids to understand why kids are less likely to get it.


They've never studied this topic. Someone might say, well, why did we really need to study his area? So anyway, long story that said, shortly is that, yeah, there's, there's unbelievable co-operation happening. And I think this is why you see so many of these scientific breakthroughs that are happening. And it's, and we should be reminded- it feels slow.


It's breakneck speed. We've never produced a vaccine in a year, let alone- It's been- the quickest has been four years, I believe, it's at least three, I think it's four years. New therapeutics coming out, these advances in testing that I talked about, all of this is happening, really extraordinary, an extraordinary pace, and it's because of that collaboration.


KL: Great. I have a couple of questions here about some specific building types. So restaurants, Katherine asks, "Indoor dining in New York City is opening soon. How important is the ventilation system in the restaurant? If there's truly only 25% occupancy, would that de facto mean there is enough fresh air? As you said, about offices."


JA: Yeah. It becomes even more important in a restaurant for the rate, for the obvious reason, that you have people without their mask on. And so if you look at the outbreaks that have happened, including the high profile outbreak a while ago, which is just about not about rest- it's a restaurant. But it really tells you the conditions that we've talked about, no mask, recirculated air only, blowing across people infector, onto other people, and you had an outbreak.


And so those conditions, even under de-densification, exist. So this is where you think about the hierarchy of controls. The fifth one is PPE and mask-wearing, now you've taken that out in restaurants, the workers have it, but a lot of people don't. And they're talking and eating. And when you talk, you're generating more aerosols. That means your other controls have to be even stronger.


So you lose elimination because people are out and about, you can't substitute away the hazard. Administrative controls, yep, you can keep tables apart, you could de-densify, but this is where now ventilation and filtration become absolutely key along with the de-densification, because masks- if you look at all the risk models, the ones that my teams have built, other professors have built, the engineering controls reduce risk. Ventilation, filtration, de-densification reduces risk. The single biggest driver of risk reduction indoors is mask-wearing.


KL: All right, I have a question here about schools and school buildings with good HVAC systems, "Would it makes sense to just open the windows. Is that enough?"


JA: Well, that's a good question. I mean, it depends on your system. So, it starts to get, the generalized guidance, starts to get real specific real fast. But in general, if you have a good ventilation system, you're bringing in outdoor air, then no, you don't want to mess up the balancing there. But as a strategy, like for many of these schools in New York and elsewhere, opening windows is a good interim strategy. Now. I wrote a piece about this in Washington Post, maybe three weeks ago, as recognizing we are running out of time, limited time, limited resources. What can we do to get these kids back?


We had done some testing at some schools, even showing that opening the windows six inches can give you air exchange rates that are 3, 4, 5, 6, over 10, sometimes, of course, depends on the pressure differential, what's happening with the weather outside, the wind. So, all of this matters, but the idea is that, yeah, even a simple tactic, people say, Well, does that really help? Can it really help, opening up the window? People know this in their house. If you open up a window, maybe, you don't get the air movement, and you open up the door, you can start to feel a breeze with the cross ventilation going. It's a time for the real basics. The window opening can help. Importantly, though, it shouldn't be used as "we're done" at that point. I think it's a strategy to buy time to put in more permanent fixes.


Especially as we start heading into the winter. But, I also don't buy the argument that, Hey, we're gonna have to close our windows in New York, and Massachusetts where I am, in November, December. That might be true. I also think we're gonna have to get creative and clever here. If that means kids are wearing their coats or big sweaters, if that's what it's going to have to take, we're in the middle of a pandemic. And so I know people want to get back to normal, but that- kids being back at school is normal, and if that means they have to wear a winter hat indoors, I'm all for that.


KL: OK, this question is from Rebecca: "Can you recommend a publication or outline of healthy building strategies and associated costs?"


JA: Sure, but it's self-serving. So we have two Harvard Business Review articles. One I wrote a couple of years ago called "Stale Office Air is Making You Less Productive." Two, I wrote a Harvard Business Review article with my colleague John McCumber at the Harvard Business School. I forget what the title is. "Is the healthiest building in the world worth the rent?" Or something to that effect? You can look at Harvard Business Review, my name, you'll find it. 


Three, John and I also wrote a Harvard Business School case study about 425 Park Avenue right in Midtown Manhattan, L&L Holding building, Norman Foster's design, where we walk through the economic argument for healthy buildings. So it's centered, it's right in your, you know, Midtown Manhattan. So that's another one. And for- this is the plug.


Yeah, I have a book, the whole theme of the book, it came out in April, is, "Building Performance Drives Human Performance Drives Business Performance".  And I think we make a compelling argument that these building decisions are good for health. And then, we walk through how and why, and the economics of why they're good for your business, too. So a couple of resources, two HBR, I think we have an HBR podcast called Is the Healthiest Building in the World Worth the Rent. 425 Park Ave: A Tower for the People is the name of the case study at Harvard Business School, that's public. And then our book came out in April.


KL: Great. I have one last question here, and thanks again to everybody who submitted, we had a ton come in today. This question is from Sarah: "Joe, can you please speak more to the inter-relationship between energy and balancing health. Ventilation, fan power, UVGI lights, other such tactics - what are the impacts to overall energy use, carbon and climate change?"


JA: Yeah, it's a good question. That's a lot for the last question. I think what we're talking about here is, is the holistic healthy building strategy. And we try to lay this out in a couple of chapters in the book and elsewhere, that there's health within the four walls. And then our choices about our buildings influencing health, beyond the four walls, and we have to tackle all of it.


There's no shortcuts here, But, you know, you mentioned, there is some specifics mentioned there, yeah, things like UVGI will give, you, know, air cleaning without the, without the penalty, energy penalty for the pressure drop across a filter. So we have to constantly take into account all of these factors, including can we- are you doing continuous commissioning to drive- We can save energy through that. Better technologies, energy, energy recovery, ventilation.


Are we being smart about when and where we're dumping air into our buildings? So improving ventilation effectiveness, and thinking about how we design buildings in the future, can we increase ventilation effectiveness? Demand control ventilation, of course, the use of real-time environmental sensors, again, to help us refine and target and make sure we're delivering a healthy building at the lowest energy expense. That's possible, so it's all wrapped up. And when I talk about not being binary, it's true. You know, I'm not saying, hey, throw in ventilation, I don't care about climate change.


Clearly, that's central to what our team has been doing for years. And we actually have some tools we didn't really talk about. John's really familiar with this. We presented this in India first, a couple of years ago, that we would call CoBi, the Co-Benefits in the built environment, that allows you to quantify your energy savings in terms of health.


So, it's a nice extension to say, well, we can add a value proposition here, to this whole conversation. Turning energy savings back into a quantified health metric, not a hand-wavy, will it reduce carbon. We're not quite sure if the impacts are there, we know it's helpful. We can actually quantify down to the missed school days. So anyway, that's a lot, there's a lot to unpack there, right at the end. But it's a big picture. It's, yeah, healthy buildings, it's not just the people indoors. It's also about the relationship to our natural environment, which is ultimately a health conversation, too.


JM: Well, Joe, we're at the top of the hour. We really really want to thank you for spending time with us today. I know this has been really informative. We had a great turnout, ton of questions. So we appreciate you carving out your precious time to spend time with us at Urban Green. So thank you. Today's program is a great example of what we do at Urban Green. We take on the biggest challenges with the biggest solutions that have the biggest impact. If you don't know us, check us out.


We do that through our four key activities: We convene, we research, we advocate, and we educate. And today was a good example of how we can bring that together. And, Joe, we're really pleased that you are able to join us. So, thank you.