Dr. Susan Kuo is marking her 31st year as a family physician in Richmond. 

Her 30th was tough. 

“September 2022, as a family doctor, I’ve never seen in my 30 years of practice so many sick kids and families,” she says. 

Kuo expects more of the same this year, as students have returned to school—she says—without robust COVID safety measures in place. “We know that schools are the source of 70% of household cases of COVID,” she says. 

Kuo, who’s also a clinical associate professor with the UBC faculty of medicine, says clean air should be on everyone’s mind, considering BC’s recent raging wildfires, which continued to burn during the back-to-school season, belching carcinogens into the air.

Clean air in our schools is a necessity, she says, because wildfire smoke increases the likelihood of coronary disease, infections and stroke.

“But COVID is the primary reason,” she says. “COVID is the airborne virus.”

Kuo is a member of Protect Our Province BC (PoP BC)—a grassroots group of scientists, physicians, nurses and community advocates that recently published a series of open letters to the BC government, calling for safe classrooms and a return of a mask mandate. 

In an August letter addressed to the premier, health, and education ministers, and to BC parents, PoP BC warns of a potentially deadly “tripledemic” of COVID-19, respiratory syncytial virus (RSV) and the flu this fall, much as those viruses surged in children last year.

The group wants the BC government to commit to ensuring each classroom’s air is as “clean, fresh and virus-free as possible.” To that end, it’s asking the government to be transparent about indoor air quality in schools, including by requiring “a real-time public display of CO2 in all shared spaces.” 

It also is asking the government to adopt the latest guidelines handed down by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) to reduce the risk of airborne disease transmission, such as COVID-19.

“According to the ASHRAE guidelines, the reason you need to monitor the CO2 levels is it’s basically a way of measuring how good the air circulation is,” Kuo says.

But the BC government does not appear to be following the new ASHRAE guidelines, known as ASHRAE 241. In fact, those guidelines, introduced this past July, are still being studied here in BC.

“The Ministry of Education and Child Care is currently reviewing [ASHRAE 241] to ensure the guidance document aligns with the new standard,” says a ministry spokesperson in an email to Capital Daily. “The guidance document will be updated accordingly if required.”

“This makes me angry as a family doctor and a parent,” Kuo says. “They are not doing enough to keep our kids safe from COVID in schools.”

The August letter, along with a subsequent open letter published Sep. 27, also asks the government to reinstate a vigorous mask mandate.

The following day, Sep. 28, Minister of Health Adrian Dix and Dr. Bonnie Henry, the provincial health officer, announced that as of Oct. 3, “masks are mandatory in health-care settings” for health-care workers, visitors and volunteers.

“Expect to wear a mask if you’re in a hospital or health-care setting in the next few months,” Henry said.

The announcement was made amid a rise in the number of cases of COVID-19—one in 13 BC residents is believed to have been infected—and other respiratory illnesses across the province.

According to the BC Centre for Disease Control (BCCDC), the number of COVID-19 cases and deaths increased during the four-week period (Aug. 20-Sep. 16), from the previous four-week period, as did the number of people hospitalized for the virus. Meanwhile, the number of confirmed cases nearly doubled from the week of Aug. 20 to the week ending Sep. 16, according to data from the BCCDC.

But there was no renewal of the mask mandate in schools.

“We are very happy they have put mask mandates in hospitals and long-term care [homes]” Kuo says. “But we are disappointed it is not a mandate for all health-care places, such as doctors’ offices, labs, X-ray facilities, etc. Because vulnerable people, especially seniors and immunocompromised people, will not be protected in these settings.”

In an emailed response from the provincial health ministry, a spokesperson told Capital Daily the original mask mandate during the pandemic came in the context of what the world was facing at the time: severe illness in many adults as immunization was increasing but not yet at the necessary level.

“We had no vaccines available for children,” the ministry says. "We had adults who were getting very sick and putting pressure on our ICUs and hospitals, plus we had absenteeism of health-care workers and many workplaces outside of health-care were working from home.”

The ministry went on to say, “In that context, masks were incredibly important and necessary in a broad range of settings, including structured settings like workplaces and transit and schools.”

Masks still an issue, opposition says 

Three-and-a-half years removed from the start of the pandemic, the opposition Greens say masks are still necessary.

“I completely agree with the concerns expressed by Protect our Province BC and the safe schools coalition,” Green party deputy leader Sanjiv Gandhi, a former pediatric cardiovascular and thoracic surgeon at BC Children’s Hospital, told Capital Daily.

“We’ve done nothing to improve the situation over the disastrous viral season that we had last year.”

And where the province could start, he says, is by making masks mandatory for young students, much as it brought back masks in hospitals with the Sep. 28 announcement.

Acknowledging the difficult sell it can be to those who just want to see the whole COVID conversation go away, Gandhi says from the get-go, government messaging made masks a restrictive measure rather than a protective, preventative health-care measure.

“It’s insanity," he says. “We wouldn’t let kids go into the school in this day and age in 2023 with the teachers smoking, for example.”

‍Steps for clean air

The Lancet COVID-19 Commission Task Force on Safe Work, Safe School, and Safe Travel spells out four steps to having good ventilation in buildings:

• Ensure ventilation and air conditioning (HVAC) equipment is performing as intended
• Allow as much outdoor air as possible
• Upgrade to minimum efficiency reporting value (MERV 13) air filters
• Supplement with portable air cleaners (HEPA or CR boxes) where needed

A HEPA filter is a type of pleated mechanical air filter, and an acronym for "high efficiency particulate air” filter. CR or Corsi-Rosenthal boxes are do-it-yourself air purifiers made with four MERV 13 air filters and a box fan.  

“CR boxes are not expensive, people can make them with common materials that you can get from the hardware store—they do work very well," says Kuo.

To her knowledge, Kuo said only six schools in the Vancouver School District—three on the west side of the city and three on the east—have been outfitted with new HEPA filters, and she says at her daughter's high school, only two HEPA filters have been placed in the portables.

“Ideally, you would have all open windows,” Kuo says. “You would have fresh air coming in. But unfortunately some of the buildings are so old, so you have HEPA filters because you can’t have open windows.”

Kuo believes the province's plan to ensure new HEPA filters are in each classroom is dubious.

“Talk is cheap. I don’t see anything happening,” she says. “They say they have provided either filtration systems, HVAC systems, or HEPA filters—they don’t say they’ve provided both. They say ‘or’ and ‘or’ is an important word."

Kuo says she hopes the government will come to the conclusion that it needs to do more.

“What we’re saying is ‘OK, you’ve taken away all mask mandates, we’re not very well-immunized. At least clean the air. It's not enough. You need to have all those protections, but at least this will help.’”

And a point that often goes unmentioned is that clean air is not only good for a student's health, it's also good for that student's brain.

“Good ventilation results in improved learning,” Kuo says. “There are actually studies that show improved science, math, and reading scores from having good ventilation.

Kuo also points to a 2022 UN resolution declaring everyone on the planet has a right to a healthy environment, and that includes clean air.

Province promises $41M in upgrades

In its 2023 budget the provincial government pledged $41M to upgrade heating, ventilation and air-conditioning systems at 101 public schools across the province.

In an email to Capital Daily, the education ministry wrote: “To date, all classrooms and portables in BC have mechanical ventilation systems or standalone HEPA filtration units, and school districts continue to conduct regular inspection and maintenance of their HVAC systems.”

Kuo says parents want to know whether the school board is supplementing the HVACs with HEPA filters in classrooms, and whether it has placed CO2 monitors in each classroom, which would be the first line of air defence.

The education ministry says “many school districts have been able to purchase additional HEPA filtration units to have as spares, enhance already ventilated spaces, or for shared spaces within schools with the $219.4 million the province (which ponied up $194.4M) and federal government ($25M) have invested since 2020 to assist school districts throughout the province with upgrades to ventilation and filtration.” 

We tried to determine what specifically the schools in our region did to strive for the cleanest air in their classrooms as possible, but did not receive complete information.

An email received from the Ministry of Education and Child Care indicates HVAC upgrades were performed at Doncaster Elementary and Reynolds Secondary in SD61; at Spencer Middle School and Millstream Elementary in SD62; and at Deep Cove Elementary and Bayside Middle schools in SD63; and Spectrum Community School and David Cameron Elementary in Colwood each beefed up their energy systems, using money from the 2023 provincial budget.

Kuo says SD61 may have upgraded their HVACs, but she questions how extensive those upgrades were: “Are they following ASHRAE 241 by installing MERV 13 filters in schools?” she asks.

“Based upon the language they have used in the Sep. 2023 Provincial Communicable Disease Guidelines in K-12 Settings, ‘HEPA filter units can be considered in regularly occupied classrooms that do not have mechanical ventilation systems.’”

In other words, if there is mechanical ventilation there will be no HEPA filters, Kuo says.

“It's an either/or but not both. So no, unless they have changed their minds since last month, I don't believe the province is going to put HEPA filters in each classroom.” 

It’s difficult to surmise how much school districts have upgraded their air systems over the past year or two based on the information provided by the school boards. 

“I know the district has put money into upgrades,” says Ilda Turcott, president of the Greater Victoria Teachers' Association. "However, many of our schools are quite old and so I’m not sure how well or how much of an upgrade those schools are able to have because of their older systems.”

The province insists the money is there for the school boards to use.

“School districts can request funding for heating, ventilation, and air conditioning (HVAC) system improvements through the Ministry’s School Enhancement Program (SEP) and the Carbon Neutral Capital Program (CNCP),” the education ministry said in an email to Capital Daily.

“School districts are also able to flexibly address their local ventilation priorities at their own discretion through their Annual Facility Grant (AFG) allocations.”

Kuo believes only some BC schools have been upgraded, a conclusion drawn from the lack of transparency.

“If you look at the School District 39 website, which is Vancouver School board, it only goes into details about ventilation assessments and upgrades, but doesn’t specifically tell you what each classroom and each school has been given to improve ventilation,” she says.

“The District’s ventilation systems were inspected and updated at all 108 schools,” SD39’s website says. “Updates included rebuilding aging motors, replacing drive belts, repairing stuck louvres, updating controls and changing approximately 7,000 filters district wide.”

A look at the websites for Victoria's school boards reveals similar results with few indications of major upgrades.

The website for SD62—the Sooke District—was not updated, but a spokesperson said each of its 29 schools and sites had MERV 13 filters installed. 

“Wherever we have air ventilations, there is a MERV 13,” says the spokesperson, who added the school board has been replacing filters since the pandemic began in spring 2020.  

In addition, the spokesperson says, all ventilation systems are connected to sensors to monitor CO2 levels, to enable fresh air to be added to rooms when needed. Any time the sensor reads 700ppm (parts per million) of CO2 or higher, the system kicks in.

“CO2 sensors have been added to individual classrooms and in ventilation duct work to detect spikes in CO2 levels,” the spokesperson says, adding that DDC (direct digital control) systems are monitored routinely by in-house staff and/or contractors to ensure CO2 levels are adequate and to address alarms. In areas with limited ventilation, she says air purifying units have been installed. 

The spokesperson also confirmed that SD62 will continue to follow ASHRAE recommendations for ventilation strategies, and that mechanical engineers have advised having the classroom’s return air mixed with a high percentage of fresh outdoor air. The diluted mixture of air runs through filtration and becomes part of the new supply air to classrooms, with air being recirculated six to eight times per hour. 

Spokespeople from SD61 and SD63 offered similar information about updates made at those schools.

All Saanich schools’ HVAC systems were designed and built to ASHRAE standards for indoor quality, a spokesperson for SD63 says. That includes an inspection of ventilation systems every three months and changing filters every three months or sooner depending on location.

SD61 (Victoria) says it has “conferred with mechanical engineers about potential spread of COVID through a school’s ventilation system,” and decided to have the classroom’s return air mixed with a high per cent of fresh outdoor air “in accordance with ASHRAE pandemic specific ventilation recommendations” to reduce the risk of spreading a virus. “The School District will continue to follow ASHRAE recommendations for ventilation strategies.”

Again, we’re left to presume these are the old ASHRAE standards.

The provincial government says school districts have been upgrading their systems since the start of the pandemic.

“So, it’s not to say that other schools haven’t also had their HVACs updated or that districts haven’t invested through other funding streams in ventilation in their schools,” a spokesperson for the Ministry of Education and Child Care said.

Kuo’s takeaway: there are still more questions than answers.

“SD62 may have put MERV 13 filters in schools and CO2 monitors, but there is no mention of HEPA filters in classrooms.”

Parents try—but don’t succeed—in DIY method 

Kuo says parents have been attempting to drop off CR boxes at their kids’ schools.

“And they’ve been told by the school boards, ‘No, you cannot do that,’” she says. “They have been told this is not allowed because of the issue of inequity. I think parents should be allowed to give CR boxes, because they’re very effective at filtering the air of viruses.”

The NDP government says many school districts have purchased additional HEPA filtration units with the $219.4M the provincial and federal governments have invested since 2020 to assist BC school districts with ventilation and filtration upgrades.

"They’ve only helped a fraction of the schools across the province," the Green’s Gandhi says. 

"And trying to find out what happened to that money is like trying to find out anything else from the government—it’s just encumbered in red tape and mired in secrecy.”

The group BC School Covid Tracker, run by BC moms Kathy Marliss and Andrea Roszmann, has been tracking COVID cases, and says it’s not seen any evidence the school boards have significantly applied upgrades.

"Many schools still report having ventilation that is below the ASHRAE standards and have seen little change in the past four years," Marliss and Roszmann tell Capital Daily in an email.

"We have been told that many of the updates that were done were standard, scheduled upgrades but did not address concerns with airflow specifically regarding COVID."

And this, at a time the ASHRAE guidelines are even stricter than they were before, they remind us.

Under the old guidelines, classrooms should have a CO2 level of no more than 800-1,000ppm. Under July’s guidelines, established specifically to control infectious aerosols, 600ppm is the acceptable figure for elementary schools, and 650ppm is the new aimed-for mark for high schools.

In an emailed statement, the provincial government said: "All school districts are expected to meet standards for indoor air quality set by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE)."

Those standards are ASHRAE’s previous set of guidelines, not ASRAE 241, the more stringent guidelines with the lower CO2 thresholds.

“This is unacceptable, it is not meeting the current ASHRAE guidelines at all,” Kuo says.

‍And the real issue starts here, Gandhi says

“They’ve never admitted the problem,” Gandhi of the Greens says. “The problem is COVID is airborne—they still treat it like a droplet disease.”

He says it makes little sense that the number one recommendation out of public health is handwashing. “That does squat-all for airborne transmission.”

COVID is transmitted through the respiratory tract, just like tuberculosis.

“Tuberculosis can affect every organ. So can COVID-19,” Gandhi says. “It’s a vascular virus and it affects the blood vessels and the ACE receptors, but the general layperson doesn’t understand that because public health has never messaged it correctly.”

The government says its response “has always been—and will continue to be—based on, grounded in, science—and the knowledge and leadership in that area our BCCDC and our respected public health officials demonstrate every day.”

Politicians know better, Gandhi says, but they're not pivoting back and admitting COVID is an airborne virus because it could jeopardize the economy, and that would affect their electability, he says.

“If they were doing their jobs, which is supposed to be caring about the people of British Columbia, the ballot box should be second, then they would come out and admit it. They’re not, because they’ve succumbed to the masses that want this to be over.”

Gandhi says if the government doesn’t want to see another year of classrooms with empty desks and chairs—he points to a 35-50% absentee rate last year at BC schools—the government has to clean the air.

And that can come more cheaply than you think, he says.

“You can buy a CO2 monitor on Amazon for 49 bucks and you can go into any place, press the button and it will tell you what the level is,” he says.

The government insists it’s got this.

"To date, all classrooms and portables in BC have mechanical ventilation systems or standalone HEPA filtration units,” the ministry writes in an email.

Kuo reiterates that the “or” is very important here. “ASHRAE recommends MERV 13 filters in all schools supplemented with HEPA filters in each classroom.”

The COVID Trackers aren't confident that’s going to be enough. "Given that there are basically no measures in place in BC schools to prevent the circulation of airborne illnesses such as COVID, there is no reason to believe that absenteeism will be any better than it was this past year when many classrooms were reporting 50% absenteeism or greater."

One month into the fall curriculum, they say they are hearing regularly from parents about “multiple cases” in their children's classes. 

“There seems to be a fair number of cases, including many school staff members off sick with COVID provincewide,” the Tracker moms say.

“Unfortunately we are not able to report all of them as they don't all meet our reporting criteria—we need the families of the COVID-positive person to contact us directly and self-report. Many of the cases we are hearing about are being reported by other people.”