Moving Ahead of the Pandemic

with additions on 10 June and 15 June 2020.

SUMMARY
We talk about a “new normal” while we revert to the old normal. It could be killing ourselves instead of our economies. Hoping for the best is not a strategy. A way forward can begin with the recognition that the prevailing explanation for the transmission of the coronavirus (Level 1, proximate) leaves much unexplained. In contrast, evidence has been mounting about another form of transmission (Level 2, atmospheric), that could be the real superspreader, indoors as well as outdoors. If so, by stopping the polluting, we may be able to stop the pandemic. We could be opening up our economies selectively, to those activities and buildings that are largely pollutant-free. At stake is our health, short- and long-term, as well as the health of a globe that has had enough of our warming.

We talk about a “new normal” while we revert to the old normal. It could be taking us to a deadly impasse. Either we kill our economies by keeping them closed or, in the event of a second wave, we kill more of ourselves by opening them up. Hoping for the best is not a strategy.

There is a way forward, for the health of ourselves and our planet. Having made no progress trying to publish this in several prominent newspapers (maybe it went into the trash alongside Trump and his bleach), yet remaining convinced that it has to be heard, I post it here again, more sharply, more clearly¹, licensed in the Creative Common so that you can reprint it,  repost it, translate it, even nail its summary to the door of your favorite church, mosque, synagogue, or supermarket.

The prevailing explanation for the transmission of the coronavirus—through direct exposure to infected people —leaves too much unexplained. Why do so many people get infected without evidence of direct exposure? How come individual cases of COVID-19 can be found everywhere yet the major outbreaks are restricted to certain areas and facilities? What really stopped the outbreaks in Wuhan and South Korea? Something else must be going on.

Evidence has been mounting about the presence of another form of transmission, through polluted air. This was first reported in March by a team of researchers in Italy, was picked up by the Guardian newspaper in late April, and has recently been used with additional evidence in a report of an All Party Group in the British Parliament.²  The Italian team identified an association between atmospheric pollution and the rapid propagation of the virus, specifically that minute particles of the virus attach to particles in polluted air. Judging by earlier tests on Zika, SARS, and Ebola, the virus could remain active in the air for several hundred meters, and therefore infect people beyond a few meters.

This could explain why, by early April, all ten of the largest outbreaks of the pandemic—within China, the United States, Italy, Spain, and Germany—occurred in places of heavy pollution. The evidence that the air in some cruise ships and senior residences had high levels of contamination suggests further that the virus could circulate indoors, through ventilating systems (as was found with the legionnaires’ disease) or just in the natural flow of inside air. How else to explain why so many people locked down in their rooms become infected?  In its June issue, Environment International calls on “national authorities [to] acknowledge the reality that the virus spreads through air.”

We can call this Level 2 atmospheric transmission, to contrast it with Level 1 proximate transmission.

Level 2 atmospheric transmission is the likely superspreader, indoors as well as outdoors. While Level 1 contact can explain how individuals get infected in the first place, Level 2 exposure may better explain how the wider outbreaks occur, and why that happens in some places and not others. An individual can carry the virus to a new place and infect people nearby, but from there, polluted air may take over and do the superspreading, as it carries the virus in the atmospheres of some cities and buildings (depending on factors such as humidity, sun exposure, and air movements).

Consider Level 2 in terms of the density and duration of the active particles. The density of these tiny particles in the atmospheric air may be less than that for the heavier particles coughed into a room. But they can last longer—apparently up to hours instead of minutes—and be replaced continuously. We do know from the experience of health care workers that the longer people are exposed to the virus, the greater the chances of getting infected. Think of all those people who are exposed to polluted air, some for as much as 24/7 (indoors as well as outdoors). Go to a particular wedding in New York City and the odds of coming home with the virus could be rather high. But how often do you go to weddings? Live in the air of New York City and, even if the odds of getting infected are 1%, this amounts to 80,000 people. The city has had 200,000 cases of COVID-19. All from Level 1?

This evidence should suffice to provoke a reconsideration of how we deal with the pandemic, as well as how we investigate it. 

We require detective research, in the form of grounded learning, alongside the more formal procedures of proper research. I asked a number of epidemiologists to read earlier versions of this piece. Most were dismissive; all called for further research—one estimated two or three years of it. We can no more wait for that than can we continue to flatten the curve while waiting for a vaccine. Compare the evidence presented here with that for the hodgepodge of re-openings currently being pursued. What evidence supports the firing up of our polluting cities? While proper research must unfold as it should, we require detective research, namely the investigation of every plausible option. Is this risky? The course we are on is the risky one.

The stakes are high while the options are few. By suspending our exclusive belief in Level 1 transmission, we could be discovering all kinds of other ways to proceed. Should we open our windows to clear the air inside our buildings? Not if that brings in more dangerous air from the outside. Should we remove the masks when no one is nearby (as is now being done in some hospitals), or allow schools and plants to reopen so long as everyone can keep their distance? Not if the air inside is found to contain contaminants that could be carrying the virus.

By stopping the polluting, indoors and outdoors, we may be able to stop the pandemic. China and South Korea have been lauded for isolating their people to flatten the curve. But the greater benefit may have been serendipitous. With reduced traffic and industry, the outbreaks might have ended because the pollution abated. If so, then simply reopening our economies, however gradually, could turn out to be deadly—as we might be finding out with the coming of a second wave.

Must we force ourselves into this either/or impasse, between the flawed options of opening up and closing down? We can open up our economies selectively, where distancing is possible, by allowing activities that barely pollute to operate while keeping major sources of pollution closed until they can be cleaned up, if ever—certain power plants and factories as well as much vehicular traffic. Indoors, we can investigate every problematic space—residences and schools, offices and arenas, factories and hog plants—and allow no-one back in until experts declare the air to be safe from carrying the virus. (Smoke could be a factor in these plants, as well as in Chinese markets and at Indian funeral sites.³)

In essence, we may have to stop the polluting to stop the pandemic (#SP2SP). Beyond that, we need to stop the polluting of our bodies and our minds to rebalance our societies (#SP2RS). Does this sound harsh? Compare it with what we are doing now.
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In a 2003 poll, the British medical establishment chose Dr John Snow as their greatest physician. But in his lifetime, Dr Snow was dismissed by that establishment for questionning its belief that cholera had to be transmitted through air. During an outbreak in London in 1854, Dr Snow placed a pin on a map where each person had died. All but two clustered around one well. He travelled to the home of one of the outliers, where he was told that she preferred the taste of the water in that particular well and had it brought to her, also that her niece liked that water too. She proved to be the other outlier.  And so, while the medical establishment was frantically trying to cope with the outbreak, the handle was taken off the well and it ended. But not the cholera: 12 years passed, and many more people died, before the case for the transmission of cholera through polluted water was finally accepted. How long, and how many more deaths, before the case for the transmission of Covid-19 through polluted air will even be considered? We don’t have 12 weeks.
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We need a win. Recognizing Level 2 transmission alongside Level 1 offers a win-win, a way forward for our immediate and long-term health as well as for the health of a globe that has had enough of our warming. And what if we take this seriously and it turns out to have been wrong? Good. Finally, we will have dealt with our long-term health and global warming. So please take this seriously!

© Henry Mintzberg 2020. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. For the questioning of more correctness in health care, please  see my book Managing the Myths of Health Care.

I am grateful to all those who have contributed to this effort during the past two mad months, some not necessarily having supported my position.
For investigating:  Hanieh Mohammadi, Paola Adinolfi, Simon Hudson, Alex Anderson, Pierre Batteau, and Diane Marie Plante
For suggesting sources:  Natalie Duchesne, Lisa Mintzberg, Susan Mintzberg, Leslie Breitner, John Breitner, Joanne Liu, Jonathan Gosling, Karl Moore, Rosamund Lewis, and Donald Berwick
For supporting professionally: Rick Fleet with Jean-Simon Letourneau and our mcgill.ca/imhl Blindspots group, Toby Heaps and the Corporate Knights, Matthew Chapman and the Montreal Climate Coalition, also Bill Litwack for some early editing
For supporting behind the scenes:  Santa Balanca-Rodrigues and Phil LeNir as well as Marie-Michele Naud
And for supporting all this substantially as well as me personally, last and most: Dulcie Naimer

¹ My blog on 31 March—“Investigating the Cause of the Coronavirus”—identified what I believed to be various anomalies associated with the coronavirus. On 2 April, I read an email from Nathalie Duchesne about the Italian researchers’ report and replied immediately: “WOW!! It could be travelling through air!! I was just musing. On particles. So taking the cars off the road could stop it!!” I published “Part II: Explaining the Anomalies” on 5 April. Since then, I have redrafted the above more than 20 times (with a revision posted here on 2 May), all the while trying to publish it on a prominent op ed page. Two said no; there was no reply from five others. (Too little science for the “opinion” page?)  Eventually, I hope to do a blog about Scientism in the time of COVID-19.

² On May 29,  in a medRxiv preprint, researchers in the MRC Toxicology Unit at the University of Cambridge reported: “Our model indicated that exposure to PM2.5 and PM10 [pollutants found in outdoor and indoor air] increases the risk of COVID-19 infection.”  

³ Meat-packing plants have been the scenes of extensive outbreaks of Covid-19, apparently more than in other plants where people also work in close proximity. The BBC reported on 24 April that “When scientists analyzed hospital admission records in Brazil, they found that the number of flu cases tended to go up during the burning season, when there is more smoke in the atmosphere…” The report explained that the smoke blocked the solar ultraviolet light that would have killed the virus. But how did that virus get into that atmosphere in the first place? If the coronavirus hitches itself to particles of smoke too, might that explain some of these outbreaks: that infected air from the process of smoking meats such as bacon and ham could be a superspreader, within these plants and/or the nearby communities? “A small number of employees at the Wisconsin and Missouri facilities have tested positive for COVID-19... Both plants are located near areas where ‘community spread of COVID-19 has been prevalent’” (Business News). Moreover, might smoke from the BBQing of meat in Chinese markets better explain the spread of the coronavirus than the presence of exotic animals? And how about the funeral pyres of India: the more people die, the more the cases of CVID-19?

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