Article "Toxic Airborne Events"; politics and history of germ-theory vs miasma; reluctance to adopt airborne mode of transmission for Covid

[wathe]

This is a really thoughtful article

https://thebaffler.com/salvos/airborne-toxic-events-ehrenreich

I'd read some about the history of germ-theory vs miasma theory, and how that has played into delay in the medical establishment accepting airborne transmission as the primary route of transmission for Covid.  This article adds a lot of nuance, particularly with respect to the historical role of politics and capitalism and colonialism.  It's worth taking the time to read.

Quotes:

"So why did droplet transmission become the dominant paradigm? Apparently, several media accounts suggested, it all had something to do with the nineteenth-century victory of germ theory over the medieval superstition that illness spread through miasmatic clouds: a battle with such “high stakes,” in Tufekci’s words, that it still makes epidemiologists sweat.

If that explanation is unsatisfying, it is also largely fictional. The battle fought in that era was not a noble crusade of science against superstition, as modernist mythmaking would have it, but a political struggle. The stakes then were not different from what they are today: the role of state and commerce in society, the degree to which “free” markets could be permitted to rule. Aerosol transmission was never merely a medical question. Accepting it, as Dr. John Conly, an infectious disease specialist advising the WHO on its Covid guidelines, told Reuters that first summer, “would affect our entire way of life.”

"The ultimate victory of germ theory was not a triumphal tale of science vindicated but a complex history in which epidemiology was bound up with the politics of capital and empire. Ackerknecht’s fundamental insight, that, as Baldwin put it, “prophylaxis is a continuation of politics,” these days feels truer and more pertinent than ever."

"“It was a common saying of sanitarians of years ago that for every death from typhoid fever someone ought to be hung,” whether it be “the city councilman, the health officer, or the landlord,” Chapin wrote. “It is more in accord with present day knowledge and modern conditions to say that if a man has typhoid fever it is his own just punishment for sanitary sins.”"

These 2 paragraphs about Chapin could have been written about current covid policy:

"His philosophy would soon be put to the test. The influenza pandemic known as the Spanish Flu arrived in 1918. By the time its fourth and final wave faded in the spring of 1920, it had killed between seventeen and one hundred million people, many of them no doubt responsible consumers of the cleanest comestibles. Chapin, who at the time headed Providence’s health department, played a role that will now be familiar. Believing that the outbreak would “run its course” within about six weeks, he consistently advised Rhode Island’s governor not to bother closing schools, churches, or theaters. “Community action cannot check the disease,” he wrote in the Dallas Morning News, but “the individual can do something to protect himself.”

A few years earlier, Chapin had acknowledged that tiny droplets containing “the influenza bacilli” could float in the air for as long as five hours. Now he kept his own counsel and said nothing about the possibility that the virus was airborne. (Aerosol transmission of Influenza A has since been confirmed in numerous studies.) He told the newspapers that the flu was “chiefly spread by droplets” and that staying “at arm’s length from everybody” should be sufficient protection so long as you “put nothing in the nose or mouth except what belongs there” and don’t “let people talk in your face.” As soon as cases began to drop, Chapin declared the outbreak over. The state’s ban on public gatherings, imposed despite his misgivings, was lifted one week later. That was late October. Predictably, deaths began to surge again before the year was out."

 

 

[prairiewindmomma]

The more things change, the more they stay the same…. 

[Katy]

Sigh. I think it has far more to do with legal designations that came from tuberculosis outbreaks and the resulting lack of airborne disease treatment rooms in hospitals. Legally, droplet precautions and airborne precautions are drastically different. The sorts of PPE nurses wear for droplet precautions are far cheaper and widely available vs for airborne precautions. 

Every hospital “floor” or wing only has 2-4 negative pressure rooms designed to treat tuberculosis.

Flu is considered droplet protection despite evidence showing it is more airborne than previously thought. It hasn’t mattered because influenza is far less dangerous to most people. 

We don’t have the nursing staff OR the PPE to treat covid like it’s airborne. We still don’t. 

 

[Pam in CT]

re PPE "legally designated" for airborne infection being much more costly than PPE designated for droplet

5 hours ago, Katy said:

Sigh. I think it has far more to do with legal designations that came from tuberculosis outbreaks and the resulting lack of airborne disease treatment rooms in hospitals. Legally, droplet precautions and airborne precautions are drastically different. The sorts of PPE nurses wear for droplet precautions are far cheaper and widely available vs for airborne precautions. 

Every hospital “floor” or wing only has 2-4 negative pressure rooms designed to treat tuberculosis.

Flu is considered droplet protection despite evidence showing it is more airborne than previously thought. It hasn’t mattered because influenza is far less dangerous to most people. 

We don’t have the nursing staff OR the PPE to treat covid like it’s airborne. We still don’t. 

 

This may just be an issue of semantics, but if I'm understanding what you're saying here, it's the COST (both dollars and available staff) associated with designating a disease as "airborne" that discourages that legal designation? Is that right?

If so, to my mind, that's closer to the argument being made in the article -- that the "free market" and our "way of life" won't support the ~true~ medical nature of the disease.

Quote

The stakes then were not different from what they are today: the role of state and commerce in society, the degree to which “free” markets could be permitted to rule. Aerosol transmission was never merely a medical question. Accepting it, as Dr. John Conly, an infectious disease specialist advising the WHO on its Covid guidelines, told Reuters that first summer, “would affect our entire way of life.”

The unwillingness to accept aerosol transmission is following the resources available/implications to our way of life, rather than the medical science.

 

[Katy]

14 minutes ago, Pam in CT said:

re PPE "legally designated" for airborne infection being much more costly than PPE designated for droplet

This may just be an issue of semantics, but if I'm understanding what you're saying here, it's the COST (both dollars and available staff) associated with designating a disease as "airborne" that discourages that legal designation? Is that right?

If so, to my mind, that's closer to the argument being made in the article -- that the "free market" and our "way of life" won't support the ~true~ medical nature of the disease.

The unwillingness to accept aerosol transmission is following the resources available/implications to our way of life, rather than the medical science.

 

It isn’t semantics, but yes, there are legal requirements for airborne precautions that are dramatically different than droplet precautions. The resistance to changing the term is because in a hospital setting different PPE is required for airborne vs droplets. But it doesn’t seem in most cases that airborne precautions are actually needed for Covid-19. Just like actual airborne precautions aren’t needed for Influenza even though it’s more airborne than previously thought. 
 

Scientifically, it’s airborne. Legally, it isn’t. 

[goldberry]

I found this article both fascinating and informative about how even the definition of airborne needs to be reconsidered from a physics standpoint.

 

https://www.google.com/amp/s/www.wired.com/story/the-teeny-tiny-scientific-screwup-that-helped-covid-kill/amp

 

[Ausmumof3]

It’s so fascinating. Air quality seems to be a huge issue in so many late 1800s early 1900 books on education, housekeeping etc and then it’s been lost. 

[wathe]

5 hours ago, Pam in CT said:

re PPE "legally designated" for airborne infection being much more costly than PPE designated for droplet

This may just be an issue of semantics, but if I'm understanding what you're saying here, it's the COST (both dollars and available staff) associated with designating a disease as "airborne" that discourages that legal designation? Is that right?

If so, to my mind, that's closer to the argument being made in the article -- that the "free market" and our "way of life" won't support the ~true~ medical nature of the disease.

The unwillingness to accept aerosol transmission is following the resources available/implications to our way of life, rather than the medical science.

 

I think it's both.  A formal airborne designation has tremendous regulatory implications, as @Katy has described. Current hospital infrastructure is not equipped to deal with an airborne pandemic.   A formal airborne designation puts hospitals in a situation where they cannot possibly meet the standard of care required.  So, instead of spending $$$$$ on infrastructure, and/or re-writing regs to fit the current reality, we put our heads in the sand, and stick to droplet dogma.   Ontario has skirted the issue by inventing a new IPAC designation of "Enhanced droplet" - exactly the same as regular droplet precautions, with the addition of an upgrade to an N95 for the HCW.  

Ventilation in hospitals is generally very good (mine is excellent).  We've done decently well with this "enhanced droplet" model, but we still have outbreaks on wards, and a significant number of nosocomial cases that may have been avoided if we used true airborne precautions.

I think that we are at a state with the science that we can confidently say that Covid clearly isn't droplet  (meaning transmitted by heavy respiratory droplets that fall to the floor within 2m of the source patient).  And pretending it is doesn't provide people with the right mental model to be able to make good decisions to protect themselves.  The things that work for covid prevention (ventilation, filtration, very-well fitting masks that are ideally respirators) are things that interrupt airborne transmission.   Ventilation and filtration will be expensive to retrofit, and unpopular with businesses because of the expense.  It's much easier to tell people to wash their hands than it is to revamp infrastructure.  

What we need is a complete IPAC paradigm shift and a  re-write of hospital IPAC regs.   I think the momentum is there and that it will happen.  Eventually.  It's going to take years and years though.

 

[Katy]

7 hours ago, goldberry said:

I found this article both fascinating and informative about how even the definition of airborne needs to be reconsidered from a physics standpoint.

 

https://www.google.com/amp/s/www.wired.com/story/the-teeny-tiny-scientific-screwup-that-helped-covid-kill/amp

 

What a great story. Facts, personal & emotional. Really great writing and important information. Thank you for sharing. 

[Pam in CT]

Re Epidemiology, physics, war strategy and history, a parable of Repetition Fallacy

9 hours ago, goldberry said:

I found this article both fascinating and informative about how even the definition of airborne needs to be reconsidered from a physics standpoint.

 

https://www.google.com/amp/s/www.wired.com/story/the-teeny-tiny-scientific-screwup-that-helped-covid-kill/amp

 

THAT IS AN ABSOLUTELY AMAZING STORY. Holy canoli.

[wathe]

1 hour ago, Pam in CT said:

Re Epidemiology, physics, war strategy and history, a parable of Repetition Fallacy

THAT IS AN ABSOLUTELY AMAZING STORY. Holy canoli.

I know right?

Here is a link to J.L. Jiminez, Lindsey Marr et all's technical pre-print paper on the same topic.  It's absolutely fabulous.

My favourite etymological tidbit:  the word influenza comes from "influenza delle stella", ("influence of the stars") and was thought to be caused by the influence of the winter constellations.  I had no idea.  I knew that malaria comes from Italian for "bad air", but the etymology of influenza was new to me.

[Pam in CT]

23 minutes ago, wathe said:

I know right?

Here is a link to J.L. Jiminez, Lindsey Marr et all's technical pre-print paper on the same topic.  It's absolutely fabulous.

My favourite etymological tidbit:  the word influenza comes from "influenza delle stella", ("influence of the stars") and was thought to be caused by the influence of the winter constellations.  I had no idea.  I knew that malaria comes from Italian for "bad air", but the etymology of influenza was new to me.

Wait.

So now you're telling me that K Randall, the grad student kindergarten mom who cracked the code of how the 5 micron Repetition Fallacy all began, was.... an ENGLISH MAJOR???!  It just gets better and better. Did you read Dava Sobel's Longitude?

[wathe]

6 hours ago, Pam in CT said:

Wait.

So now you're telling me that K Randall, the grad student kindergarten mom who cracked the code of how the 5 micron Repetition Fallacy all began, was.... an ENGLISH MAJOR???!  It just gets better and better. Did you read Dava Sobel's Longitude?

Not yet.  It's in my to-read stack though!

[goldberry]

10 hours ago, Pam in CT said:

a parable of Repetition Fallacy

 

EXACTLY!  Crazy, huh?

[goldberry]

So are they really saying here that we are so ill-equipped to actually survive a lethal airborne disease that we just should forget about even trying?  Not that they are SAYING that, but in practice.

I confess I worry the most now that people are going to use "we survived Covid" and "kids should have stayed in school" to argue the next time something comes around we should do nothing.  And what if "next time" is something truly horrible and even WORSE than what Covid is...  I remember thinking early in Covid that this was like a practice run for a seriously lethal pandemic and we failed the practice miserably.

Edited March 29, 2022 by goldberry

[Katy]

31 minutes ago, goldberry said:

So are they really saying here that we are so ill-equipped to actually survive a lethal airborne disease that we just should forget about even trying?  Not that they are SAYING that, but in practice.

I confess I worry the most now that people are going to use "we survived Covid" and "kids should have stayed in school" to argue the next time something comes around we should do nothing.  And what if "next time" is something truly horrible and even WORSE than what Covid is...  I remember thinking early in Covid that this was like a practice run for a seriously lethal pandemic and we failed the practice miserably.

Yes, we lack the capacity to handle that. 

[Harriet Vane]

34 minutes ago, Katy said:

Yes, we lack the capacity to handle that. 

This breaks my heart. I see it playing out every day, and I get really upset about it at church. The obvious thing is to open windows and run fans, especially because everyone refuses to mask, but they will not do so.

There are Japanese studies that show what a dazzling difference ventilation makes.

Folks are very, very reluctant to open a window or run a fan where I am. There is a serious disconnect over this idea that I just do not understand. And yet doing such a simple thing would really help with ALL the pathogens out there.

[Pam in CT]

re "Since we can't afford to install UV lights and effective ventilation in every classroom, just fuggedabout even trying to do ANYTHING AT ALL" thinking

53 minutes ago, Harriet Vane said:

This breaks my heart. I see it playing out every day, and I get really upset about it at church. The obvious thing is to open windows and run fans, especially because everyone refuses to mask, but they will not do so.

There are Japanese studies that show what a dazzling difference ventilation makes.

Folks are very, very reluctant to open a window or run a fan where I am. There is a serious disconnect over this idea that I just do not understand. And yet doing such a simple thing would really help with ALL the pathogens out there.

It is astounding. Like... we.can.open.the.doors.and.windows. 

We really can. People can bundle up a bit. We can turn up the heat a bit.

It will not solve 100% of the problem. There will still be ongoing transmission. Over the weeks and months ahead, new variants will still likely emerge.

Less transmission is better. Fewer cases is better.

It's just so weird.

 

[Terabith]

4 minutes ago, Pam in CT said:

re "Since we can't afford to install UV lights and effective ventilation in every classroom, just fuggedabout even trying to do ANYTHING AT ALL" thinking

It is astounding. Like... we.can.open.the.doors.and.windows. 

We really can. People can bundle up a bit. We can turn up the heat a bit.

It will not solve 100% of the problem. There will still be ongoing transmission. Over the weeks and months ahead, new variants will still likely emerge.

Less transmission is better. Fewer cases is better.

It's just so weird.

 

Except, we can't.  At least not in the schools I've taught in or that my children attend.  

Heating/ ac efficiency and fear of active shooters have made it so that none of the buildings have windows that open.  Many of the buildings don't even HAVE windows.  Almost every school in our district would have to be completely replaced in order to open windows.  

[wathe]

54 minutes ago, Pam in CT said:

re "Since we can't afford to install UV lights and effective ventilation in every classroom, just fuggedabout even trying to do ANYTHING AT ALL" thinking

It is astounding. Like... we.can.open.the.doors.and.windows. 

We really can. People can bundle up a bit. We can turn up the heat a bit.

It will not solve 100% of the problem. There will still be ongoing transmission. Over the weeks and months ahead, new variants will still likely emerge.

Less transmission is better. Fewer cases is better.

It's just so weird.

 

And this is the problem. We absolutely can mitigate airborne infections.  It's a solvable problem.  Open windows, run HEPA, run Corsi-Rosenthal boxes, upgrade ventilation.   Tie capacity limits to air quality.  Fund ventilation re-fits.  Mandate real-time air-quality monitoring, and public display of air-quality indicators.  It absolutely can be done.  

But, in order to convince people to do this, we have to give them there right mental models, and the right public health messaging.  We have to, loudly, publicly, officially, acknowledge that it's airborne.  But we don't, because of politics and inconvenience.  So public health's hands are tied - they can't both recommend airborne mitigation ('cos that's what works), and say that it's not airborne ('cos formally calling it airborne has huge, huge regulatory implications that there isn't the political will to address).  

So instead, you get waffly public health messaging, hygiene theatre, and a whole lot of covid circulating in the community.

[wathe]

You know, thinking on this further, hospitals could have at least tried to manage this as airborne.  It would be hard, but probably not impossible.  And during a pandemic crisis, regulations may have to be bent - that's why we have formal crisis standards - we could have used them.  Just thinking out loud here:

We sometimes get surprise airborne patients in the ED who are not in negative pressure rooms (Usually chickenpox, sometimes Tb, rarely measles).  Most pts do not arrive in the ED with a diagnosis, the diagnosis is made while in the ED - often after they've been there a while.  We cope.  We put a free-standing high flow HEPA filter into the room with the patient.

At the very least, an airborne designation could be managed by hospitals by putting staff in proper PPE, and putting HEPA filtration in regular rooms with known covid patients.  That's doable (maybe it wasn't right at the beginning, but is is now).  

If we call it airborne, then we'd have to at least try. Humans are great at coming up with ingenious jury-rigs (Corsi-Rosenthal boxes!)  But we persist with droplet dogma, so we don't have to bother trying.

[Harriet Vane]

2 hours ago, Pam in CT said:

re "Since we can't afford to install UV lights and effective ventilation in every classroom, just fuggedabout even trying to do ANYTHING AT ALL" thinking

It is astounding. Like... we.can.open.the.doors.and.windows. 

We really can. People can bundle up a bit. We can turn up the heat a bit.

It will not solve 100% of the problem. There will still be ongoing transmission. Over the weeks and months ahead, new variants will still likely emerge.

Less transmission is better. Fewer cases is better.

It's just so weird.

 

YES, It is sooooo weird. I look at all the crazy measures people take to have tailgate parties or watch football games in Chicago when it's frigid out,, but they cannot apply the same hearty creativity and cheerfulness to covid prevention. They refuse. Even people who believe covid exists and who have gotten vaccinated by and large will not entertain ventilation measures.

@wathe I agree 100%. We have got to try, yet most people will not. The matter is deemed impossible and the door is shut.

 

I am mystified and it really breaks my heart.