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[36]Health

We’re Just Rediscovering a 19th-Century Pandemic Strategy

The first way to fight a new virus would once have been opening the
windows.

[37]Sarah Zhang

February 22, 2021
Three men sit in outdoor hospital beds with Westminster Palace in the
background.
Fox Photos / Getty

A few years ago, when I still had confidence in our modern ability to
fight viruses, I pored over a [38]photo essay of the 1918 flu pandemic.
How quaint, I remember thinking, as I looked at people bundled up for
outdoor classes and court and church. How primitive their technology,
those nurses in gauze masks. How little did I know.

I felt secure, foolishly, in our 100 additional years of innovation.
But it would soon become clear that our full-body hazmat suits and
negative-pressure rooms and HEPA filters mattered little to Americans
who couldn’t find N95 masks. In our quest for perfect solutions, we’d
forgotten an extremely obvious and simple one: fresh air. A colleague
joked, at one point, that things would have gone better in the pandemic
if we still believed in miasma theory.

Miasma theory—discredited, of course, by the rise of germ theory—held
that disease came from “bad air” emanating from decomposing matter and
filth. This idea peaked in the 19th century, when doctors, architects,
and one particularly influential nurse, Florence Nightingale, became
fixated on ventilation’s importance for health. It manifested in the
physical layout of buildings: windows, many of them, but also towers
erected for the sole purpose of ventilation and elaborate ductwork to
move contaminated air outdoors. Historic buildings still bear the
vestigial mark of these public-health strategies, long after the
scientific thinking has moved on.

Recommended Reading

* [39]a lung overlaid with silhouettes of the coronavirus

[40]Coronavirus Reinfection Will Soon Become Our Reality
[41]Katherine J. Wu
* [42]A timer or sundial in the shape of a coronavirus

[43]A Simple Rule of Thumb for Knowing When the Pandemic Is Over
[44]Alexis C. Madrigal
* [45]Four people sit filling vials with vaccine using syringes.

[46]The One Area Where the U.S. COVID-19 Strategy Seems to Be Working
[47]Olga Khazan

Recommended Reading

* [48]a lung overlaid with silhouettes of the coronavirus

[49]Coronavirus Reinfection Will Soon Become Our Reality
[50]Katherine J. Wu
* [51]A timer or sundial in the shape of a coronavirus

[52]A Simple Rule of Thumb for Knowing When the Pandemic Is Over
[53]Alexis C. Madrigal
* [54]Four people sit filling vials with vaccine using syringes.

[55]The One Area Where the U.S. COVID-19 Strategy Seems to Be Working
[56]Olga Khazan
*

The obsession with ventilation—and miasma theory in general—was indeed
wrong when it came to pathogens such as cholera and yellow fever that
we now know spread through other means (water and mosquitoes,
respectively). But it did make sense for the diseases that invisibly
stalked people through 19th-century air: measles, tuberculosis,
smallpox, influenza—all much diminished as threats in the 21st century.
“We’ve gotten so good at preventing so many diseases, there’s been a
loss of knowledge and a loss of experience,” Jeanne Kisacky, the author
of [57]Rise of the Modern Hospital, says. Science is not a simple
linear march toward progress; it also forgets.

Today, amid a pandemic caused by a novel airborne virus, these old
ideas about ventilation are returning. But getting enough schools and
businesses on board has been difficult. Fixing the air inside modern
buildings, where many windows don’t or barely open, means fighting
against the very nature of hermetically sealed modern buildings. They
were not built to deal with airborne threats. Nineteenth-century
hospitals were.
__________________________________________________________________

That era saw the rise of well-ventilated “Nightingale pavilions,” named
after Florence Nightingale, who popularized the design in her 1859
book, [58]Notes on Hospitals. As a nurse in the Crimean War, she saw
[59]10 times more soldiers die of disease than of battle wounds.
Nightingale began a massive hygiene campaign in the overcrowded
hospitals, and she collected statistics, which she presented in
pioneering infographics. Chief among her concerns was air. Notes even
laid out exact proportions for 20-patient pavilions that could allow
1,600 cubic feet of air per bed.
Inforgraphic showing both soldier deaths were caused by disease
Florence Nightingale / [60]Wikimedia Commons

Each pavilion was a separate wing, radiating from a central corridor.
And it had large windows that faced each other, which allowed a cross
breeze to blow between the beds. The windows stayed open no matter the
weather. There were stories, Kisacky told me, of hospitals in winter
where “the patients are closing the windows, and the nurses are opening
them. And the doctors come and knock the glass out to make sure they
stay open.” In some pavilions, a central fireplace heated the room, so
that contaminated air rose out of the ward via the chimney effect. That
heat might have been nice in the winter but “they would run fires in
the fireplaces in August to keep the air moving,” Kisacky said. “You
wouldn’t want to be the patient in the bed closest to that.”

The pavilion-plan hospitals formalized the fear of “bad air” in
hospital design, but the idea is much older. The Greek physician
Hippocrates warned in the fifth century B.C. that bad air was the cause
of pestilence. People in the Middle Ages believed some version of this
too. The word miasma, which dates to the 17th century, comes from the
ancient Greek for “pollution.” In the 19th century, the fear of
outbreaks fueled new [61]sanitation campaigns to rid cities of miasma.

Homes needed ventilation as well. In Victorian England, reformers
successfully fought a window tax that penalized large windows, says
Henrik Schoenefeldt, an architectural historian at the University of
Kent. Bigger windows meant better ventilation. One doctor, Schoenefeldt
told me, even railed against small windows as a “crime” that was
killing people. When I was Zooming with another historian of
architecture, Harriet Richardson Blakeman of the University of
Edinburgh, she pointed her webcam up toward the ceiling. Above the door
was a grate, which ventilated the room that had become her office in
her Victorian-era home. (Blakeman thinks the grate may have actually
been added some decades after the house was first built, as ventilation
continued to be a concern.)

The massive growth of cities in the 19th century also sparked the
creation of bigger and more elaborate public buildings, which meant the
creation of bigger and more elaborate ventilation systems in new
museums, prisons, and courthouses. “There are new types of buildings
being invented to respond to urbanization,” Alistair Fair, an
architectural historian also at the University Edinburgh, says. This
was a time of innovation in ventilation too. In these complicated
buildings, simple windows and chimneys would no longer do. Instead,
intake vents were installed, as were ducts that wove through the walls
and floors.
Rows of hospital beds with windows open behind them Harrison /Topical
Press Agency / Getty

A famous example is the Palace of Westminster, in London, whose
construction began in 1840. The building’s architect consulted with a
doctor, David Boswell Reid, and Reid suggested extensive revisions to
the architectural plan to improve ventilation. The two iconic towers of
Westminster—the Victoria Tower and the one that holds Big Ben—are both
also ventilation towers that helped draw warm, stale air out of the
buildings. Reid further insisted on an expensive third tower, the
Central Tower, for the sole purpose of ventilation. The ventilation
system as a whole, which also included mechanical fans, valves, and a
series of air chambers in the basement, accounted for a quarter of the
building’s costs. Physically, too, “that system, when it was completed,
took up about a quarter of the entire building,” said Schoenefeldt, who
has [62]extensively studied [63]historical ventilation in Westminster.

The system’s physical remnants are still in the building, now unused.
Even in the 19th century, the building’s ventilation did not always
work as designed—Reid was a doctor, not an engineer, after all—but the
principles of his designs were influential. “The Palace of Westminster
was, at the time, the technologically most sophisticated building
constructed in Europe,” Schoenefeldt told me. Its ventilation system
inspired those in the era’s new museums, concert halls, and
courthouses.

By the late 19th century, scientists were developing the beginnings of
germ theory. John Snow had drawn his famous map of a cholera outbreak,
which he traced to a single water pump. Louis Pasteur had shown that
organisms cannot spontaneously generate in sterilized broth. And Robert
Koch had identified the microorganisms that cause tuberculosis,
cholera, and anthrax. But germ theory did not immediately do away with
the importance of fresh air. “Early understandings of the germ, which
emphasized its ubiquitous presence in air and water and its hardiness
outside the body, neatly harmonized with already accepted modes of
protection,” Nancy Tomes, a science historian at Stony Brook
University, writes in The Gospel of Germs. The shift, like most
paradigm shifts in science, was gradual.

For hospitals, the pavilion style continued into the 1930s, Annmarie
Adams, an architectural historian at McGill University, told me. The
1918 flu pandemic struck at a time when germ theory was taking hold but
people still recognized the importance of air. Even in modern hospitals
today, where hand-washing and disinfection are paramount, the flow of
air remains tightly controlled. Infectious patients are put in
negative-pressure rooms, which contaminated air cannot escape.
Immunocompromised patients are put in positive-pressure rooms, where
contaminated air cannot enter. If anything, the flow of air is
controlled in ever more sophisticated ways.

Outside hospitals, though, the menace of “bad air” has faded away.
Airborne diseases simply don’t exist the way they did 100 years ago,
Tomes says. Measles and smallpox have been vanquished through vaccines.
Tuberculosis is treatable with antibiotics. The common remaining
airborne pathogens are the cold and flu, diseases taken so unseriously
that you might be docked for missing school or work on account of them.
Without deadly airborne pathogens in the literal air we breathe, we’ve
lost an intuitive sense of their invisible danger. And we’ve lost the
relatively simple ways of mitigating that danger. Fresh air became less
important; homes and workplaces were sealed up for energy efficiency.

Imagine, Tomes said to me, a sci-fi movie featuring a scary new virus.
You would probably picture people protecting themselves with space
suits and respirators. “Nobody ever goes to open a window,” she said.
Who would have thought that the key to fighting this novel coronavirus
would be as simple as fresh air? Only everyone 100 years ago.
__________________________________________________________________

Before COVID-19 hit last year, Linsey Marr, an environmental engineer
at Virginia Tech, was one of the few scientists already studying
airborne transmission of viruses. She told me she would read medical
textbooks that claimed pathogen-laden droplets from our mouths fell to
the ground within six feet. Until recently, however, scientists
couldn’t measure what remained airborne, because they had no way of
collecting delicate live viruses from the air.

There were other signs the textbooks were off, though: Marr knew, based
on simple calculations she did with her undergrad students, that
droplets of a certain size could linger midair. And papers going back
decades suggested that common respiratory ailments such as the flu were
indeed airborne, which official medical sources kept downplaying. “I
just kind of figured, well, maybe 30 years from now, people will look
back at these papers, mine and other people’s, and realize, ‘Oh yeah,’”
she said. “Finally there’ll be enough evidence showing that these
diseases are really transmitted by breathing in virus from the air.”

Then a mysterious new respiratory virus began sickening people in China
at the end of 2019. Scientists quickly identified it as a novel
coronavirus, but it took several more months for health agencies to
acknowledge that COVID-19 spreads through air—a blip in the normally
glacial pace of science but a long time in an emergency when cases are
growing exponentially. Experts were initially reluctant to label the
virus “airborne,” because they typically used that term to describe
pathogens that linger infectiously in the air for hours, such as
measles. The coronavirus doesn’t seem to last as long, but it can still
transmit through the air when people talk and breathe. [64]The smoking
gun, in Marr’s view, was a study that found live viruses lingering in
the air seven to 16 feet away from patients. Super-spreader events and
asymptomatic spread—when people aren’t coughing or sneezing—offer
additional circumstantial evidence, she said, that the virus is
spreading via small aerosols from breathing and talking.

In July, she was one of [65]239 experts who signed an open letter to
the World Health Organization outlining the evidence for airborne
transmission. The WHO [66]eventually acknowledged airborne
transmission, as did the CDC, finally, in [67]October. In retrospect,
it’s remarkable how long it took to say what should be intuitive: A
virus that infects the respiratory system spreads through air. “It
seems like it would be obvious, right?” Marr said. A 19th-century
doctor, who didn’t even know what viruses were, might have thought so
too.

Still, early advice that focused on hand-washing and sanitizing
surfaces has stuck, as evidenced by the [68]hygiene theater that
continues to pervade public spaces. Genuine confusion exists about the
changing scientific consensus, but so does inertia. Wiping surfaces and
erecting [69]plexiglass barriers is easier than installing expensive
air filters or, God forbid, reconfiguring a hermetically sealed
building’s entire ventilation system. Even the CDC’s school-reopening
guidelines, released just this month, [70]said little about
ventilation.

Like so many viruses before it, the coronavirus is likely to be tamed
by vaccines. Perhaps soon, ventilation won’t matter again. But COVID-19
is a humbling reminder of the value of lost knowledge.

I’m writing this now at my desk, which is in front of a radiator, which
is in front of a window. For apartment buildings like mine, built in
the early 20th century, this is by design. The radiator runs too hot,
so that residents can keep the window open for ventilation. (I am
indeed too hot. The window is open.) This quirk of old building design
[71]went viral months ago in a collective “Aha!” moment. This thing
that never made sense actually makes sense! Like many old buildings, my
apartment has pipes that somehow always need to be repaired. I remember
going downstairs one day to find a giant trench dug out in the lobby,
where a steam radiator had exploded. And in the past year of working
from home, I have cursed the lack of central AC and the overwhelming
heat of the radiators.

But the window is open today. The air is good. This is a building
designed in a time of airborne pathogens.

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