Overview Have the orthodoxies of administration and the paradigms of science restricted some efforts to broaden the conversation about this pandemic? In particular, there is neglected evidence to suggest that polluted air could be exacerbating the pandemic, in three ways: by bonding with the coronavirus to carry it farther, by blocking the sun’s UV rays to allow it to remain active longer, and by weakening the defenses of some individuals to enable it to penetrate deeper: living in polluted air might compromise their health to the point where they could get infected with low doses of the virus arriving from afar, and then, in turn, trigger local outbreaks. Locking down the pollution might thus make more sense in certain circumstances than locking down an economy. Indeed, doing so, even now, could open a window of opportunity to deal with two more deadly effects of pollution: the great many premature deaths brought on regularly by polluted air, and the potentially greater loss of life from climate change. In our science as well as our admiration, there are times when we need to ask “Why not?” instead of “Why?”
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I am not a physician, health scientist, or administrator of health care, but a professor of management who established my reputation by reframing certain views of managerial work, strategy formation, and the myths of health care. Since last March, I have been endeavouring to reframe how we see the origins and trajectory of this pandemic, with regard to several possible roles of air pollution.

The story can begin in 1854, during an outbreak of cholera in London. A Dr John Snow, spurned by the medical establishment for his belief that cholera could be transmitted through water, placed a pin on a map where each death had occurred. All but two were in the vicinity of a single well. Dr Snow visited the home of one of these two outliers and found out that both she and her niece had been drinking water from that well: her niece turned out to be the other outlier. Thus, while the medical establishment was struggling to contain the outbreak, the handle was taken off the well and the outbreak ended. But not the disease. It took twelve more years, and more deaths, before that medical establishment acknowledged that cholera could be transmitted through polluted water. Might this story have a certain relevance now, with regard to polluted air? With other pandemics likely to follow, we don’t have 12 years to find out.

SEEING BEYOND DISTANCING

We have been stuck during this pandemic between killing our economies by lockdowns or else killing more of ourselves by opening up. Yet those in authority, struggling to contain the spread of the disease, have for a year remained largely fixated on one prescription: keep a two-meter distance from other people, or else wear a mask. This has certainly been necessary advice, in the second wave more than ever, but it has not been sufficient. Doubling down is no strategy when so much remains unexplained. With so many anomalies associated with this pandemic, something else must be going on.

The distancing-or-masking prescription has focussed on the immediate transmission of the virus, through direct exposure to droplets emitted by infected people. When a number of prominent scientists asserted that tiny aerosols can carry the virus beyond two meters—perhaps across a restaurant, or through the ventilating system of a residence—the World Health Organization finally acknowledged this, at least in principle. Practice has remained largely focussed on the immediate transmission, for example, that masks should be worn only when close to others, even though the aerosols can lurk beyond that.

Some evidence appeared in March of 2020 suggesting that there may be a third form of transmission, which we can call distant, beyond intermediate. A team of scientists in Italy reported that the virus could adhere to particles of polluted air, which might carry it farther, perhaps across a city or throughout a cruise ship. Support for this comes from Peaks of Fine Particulate Matter May Modulate the Spreading and Virulence of COVID-19. This might help to explain several anomalies associated with the comings and goings of the coronavirus.

ACKNOWLEDGING THE ANOMALIES

Why have so many of the outbreaks ended so abruptly? True, people locked down cannot transmit the virus personally. But neither can people who are locked down pollute the air as they did before, from their cars and at their work. Could the clearing of the air have been a serendipitous consequence of the lockdowns? And, if so, might the reopening of an economy, to polluting as usual, help to explain some of the second waves of the pandemic? If so, should countries have been locking down their pollution instead of their economies?

Why can we still not trace the origins of so many cases of this disease? And why is it that the cases have appeared so widely but not the outbreaks? Can COVID-19 be more contagious than we believe? Or less? Or both? The outbreaks seem to have concentrated in some locations, gatherings, and facilities but not others—for example, in certain cities, weddings, and residences. Indeed, many packed events have escaped outbreaks altogether, and so have some seniors’ residences. Can this really be put down to masking and washing, etc, or do we simply see explanations in what we already believe? Some unexpected places have experienced outbreaks, such as around hog farms in Holland and in a remote area of southwest Iran, while airplanes, where people sit closely together, have not.

The coronavirus seems to spread in steps from place to place, as if on what mathematicians call a random walk. Is "random" just a label for a pattern waiting to be discovered? On the other side of this coin, why have several variants appeared at around the same time yet in such different places?

Earlier studies of some seniors’ residences as well as cruise ships found high levels of contamination in the air. Might the circulation of such air help to explain some of their outbreaks, especially when people were locked down in their rooms? Outdoors, the team of Italian scientists found that the outbreaks in Italy tended to occur where there was extensive air pollution. In April, we found that the ten largest outbreaks worldwide, in China, the United States, Italy, Spain, and Germany, all occurred in such areas.

FARTHER, LONGER, DEEPER

Many diseases are exacerbated, if not caused, by pollution, whether of the air, water, or food. Might COVID-19 be one of them? Polluted air could be contributing to this pandemic in three ways: by bonding with the virus to carry it farther, by blocking the sun's UV rays to allow it to remain active longer, and by weakening our defenses to enable it to infect our bodies deeper.

The first effect has been discussed above. Concerning the second, a study in Brazil, finding an elevated incidence of hospitalizations for influenza when farmers were burning their trees, postulated that the UV rays of the sun, which could normally render the virus inactive, were blocked by the heavy smoke, thus enabling the virus travelling in that air to remain active for longer periods of time. This blocking could, of course, happen in a city with smog.

After reading about smoke in Brazil, I noticed its presence in a surprising number of prominent outbreaks: in and around hog plants in America that smoke pork, in a Chinese open-air market that roasts ducks, in the American embassy in Riyadh after a birthday BBQ, in the closure of several fire stations in Toronto. There has also been speculation about the effects of wildfire smoke. And how about college campuses, with the vaping and smoking of other substances, and the many funeral pyres in India: might cremating the dead be sickening more of the living? Where there’s smoke, might there be greater likelihood of COVID-19?

If bonding could allow for greater distance of travel and blocking for greater duration of activation, might this third effect of pollution counter the belief of some scientists that, even if the virus could survive all that travel, it would likely lack sufficient density (viral load) to infect people. There is evidence, however, that living in polluted air can increase the likelihood of getting infected in the first place (aside from getting more seriously infected). Such air may compromise some people's respiratory systems to enable a low density of the virus to penetrate deeper into their bodies and infect them. In other words, no matter how little of the virus might remain active after considerable travel, that might be enough to infect these people. (This could be an example of Toxin-Induced Loss of Tolerance.) And they might then pass the infection on to healthier people nearby, through the usual droplets and aerosols. These people could turn out to be superspreaders who trigger some of the outbreaks.¹ Hence the claim that most people get infected from droplets may not be quite right: a great many of them might get infected indirectly from aerosols.

While these three effects of pollution could act independently, acting together, they could be having a major impact on the spread and intensity of this pandemic, by carrying the active virus to places where a few individuals can initiate new outbreaks. This might help to explain why the cases of COVID-19 have been so widespread but not the outbreaks:

“NOT ENOUGH EVIDENCE”?

Given this evidence, with the stakes so high and the options so limited, surely a case can be made at least to investigate the role of pollution in this pandemic. Apparently not. To date, there has been little discussion of this, and my own efforts since April of 2020, asking a number of epidemiologists and op editors of prominent newspapers to consider this, have gone nowhere. (You can see several posts that I published instead on mintzberg.org/blog.) Back came the reply, when it came at all, again and again: “Not enough evidence.” Compared with what: the evidence in support of opening up our economies? Hoping for the best is not an acceptable strategy. Yet that is what most of our authorities have been doing for a year: taking refuge in the tried but not always true, instead of opening up what could be consequential conversations.

One epidemiologist suggested that establishing the necessary evidence could take two to three years. We need proper evidence, to be sure, but while waiting for conventional science to deliver, we could be extending its reach in other ways: we have to investigate every plausible option about the cause and spread of such a disease, beside developing treatments for it.

“WHY NOT?” RESEARCH

In research, inference has to precede as well as follow the collection of evidence. In other words, ideas have to drive investigation, in the manner of Dr Snow. There are times when we need to ask “Why not?” instead of “Why?” It has been said before, and needs to be said again, that absence of evidence is not evidence of absence.

Dr Snow could not wait for the endorsement of his naysaying colleagues, so he went ahead and investigated his inference personally, engaging himself in inductive learning, on the ground. We can call this detective research, since it is in the spirit of a Sherlock Holmes more than a Karl Popper.²

Unfortunately, a dismissive attitude of “Why?” has prevailed among many of the authorities in medicine and management during this pandemic, at least with regard to ideas outside their own paradigm (a worldview that is used to explain everything except outliers and anomalies). We like to believe that we believe what we see. Too often, we see what we believe. As the rise of infections turned around so sharply in early 2021, an American health care authority commented on the CBC: “I think there's also this evidence that people are being a bit more assiduous about mask-wearing and social-distancing." Have a look at the spikes in infection rates in so many countries (the U.S., France, Italy, Poland, Colombia, Canada, Netherlands, Nepal, etc.), Why do we see such pronounced inflection points— not gradual changes over even a few days , but sharp rising followed by sudden, prolonged drops, some of them at the same time? Surely this can hardly be explained by greater acceptance of masking and distancing. To repeat: what else could be going on?

The World Health Organization long resisted, first asymptomatic transmission of the virus, and then aerosol transmission. Two blind spots. (An aerosol expert I know has resisted the idea of outdoor transmission: his seems to be an indoor paradigm. if the aerosol can circulate in a restaurant, why not to an adjoining terrace, then to a street of such terraces, finally across a polluted city with several such streets?). Might the effects of polluted air turn out to be a third blind spot?

All research is flawed, just as all theory is false. Research is an imperfect search for better explanations of reality; theory is an abstraction of that reality—symbols on paper or screen, not reality itself. This means that we must choose our theories according to how useful they are, not how true, or false. (The flat earth theory works just fine to build soccer fields in Holland. Mountain climbing would not be a sport on a truly round earth.) The day I began to do empirical research, I discovered how insightfully serendipitous reality can be. (I was observing chief executives at work, who were not doing what half a century of literature claimed they did.). That is why we need more of a “Why not?” attitude in our research—to open up our conversations rather than closing them down.

How else, then, to do research for the advancement of practice? Just as did Dr Snow: investigate the outliers for whatever could prove to be significant; smoke out the causes; and, especially, experiment—take the handles off the wells.

JUST TRY IT

There is a great deal that we can try here without taking undue risks. We can suspend the smoking activity in some problematic hog plants or college campuses³ to see the effect on infection rates.⁴ We can check schools, offices, factories, seniors’ residences, and arenas, to ensure that they are free of airborne contaminants that might carry the virus. And in cities with outbreaks, we can try selective closings instead of general openings: close down the heavy emitters of pollution to see what that does.⁵

Stopping pollution may no more stop a pandemic than will keeping our distances and wearing masks. But together, these may work more effectively. More generally, we have to reframe the questions we ask, to allow some fresh air into our investigations.

BEYOND THE PANDEMIC

We face two effects of air pollution that are of greater consequence than this pandemic: premature deaths and climate change.

Estimates of deaths every year as a consequence of polluted air range from four to eight million. We hardly need more evidence to do something about this. And climate change may well end up taking a lot more lives, and change life on earth as we know it. Forty-year plans from four-year governments will no more deal with climate change than will racing to create vaccines free us of pandemics.

This pandemic opens a window of opportunity to deal with the deadly effects of pollution. Miss it, and we may not get another. Seize it, and our progeny will be forever grateful.

ADDENDUM

In the summer of 2021, 16 months after the first version of these ideas were posted, a number of articles began to appear that supported them:

Wildfire smoke has caused rise in Covid infections and deaths, study finds(Guardian 13 August 2021)
COVID piggybacking on soot? Researchers link stubble burning to Delhi’s 3rd wave in November 2020
The impact of outdoor air pollution on COVID-19: a review of evidence from in vitro, animal, and human studies
Climate change is sparking wildfires that are amplifying Covid (CNN 25 August 2021)
See also: Peaks of Fine Particulate Matter May Modulate the Spreading and Virulence of COVID-19
Fine particulate matter from wildfire smoke more harmful than pollution from other sources
Can Secondhand Smoke Transmit the Novel Coronavirus?

© Henry Mintzberg 2021. A video summary of this is also available.

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¹ "...inhalation transports the particles deep into the lungs, especially those smaller than 2.5 microns (PM2.5 and UFPs), and this allows the virus to develop within the respiratory tract and to cause infections…. After having demonstrated the positive correlation between viral infections in the respiratory tract and exposure to PM, it is necessary to analyze the mechanism by which exposure to these agents can impact the subject’s susceptibility and immune response to infection. As respiratory tract cells are the first target of PM, as well as the first target of respiratory viruses, pathogens will invade already compromised cells if subjects are exposed to PM for a long time." (MDPI)

² Karl Popper, whose surname an assistant of mine once typed as Propper, wrote a book, widely influential among proper scientists, about The Logic of Scientific Discovery (1934, 1959). In its first four pages, in a section entitled “The Problem of Induction,” Popper dismissed this aspect so that he could devote the rest of his book to “the deductive method of testing.” Where is the “Discovery” in that?

³ Several people have assured me that there will be great resistance to this. From students who want their degrees? Or jobs after that?

⁴ Might two hog plants in the United States prove to be the outliers that help solidify the case? “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). In both, there were more cases in the nearby communities, apparently downwind, than in the plants themselves. Might, therefore, not the workers but the smoke have carried in the virus?

⁵ This, I am told, is too radical. Not at all. Because of the lockdowns, some cities now find themselves pollution-free. They could have just stayed that way, by opening up everything that does not pollute heavily. Many other cities are well on their way to this, thanks to the use of recycling and clean forms of energy as well as encouraging different kinds of commuting. The shift from manufacturing to service industries has also helped to reduce pollution, as has the regulation of heavy polluters.