We’ve gotten so good at preventing so many diseases, there’s been a loss of knowledge and a loss of experience

Saturday, February 27th, 2021

In our quest for perfect solutions to the current pandemic, 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.

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 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, Notes on Hospitals. As a nurse in the Crimean War, she saw 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.

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.


  1. Joe says:

    “Fixing the air inside modern buildings, where many windows don’t or barely open….”

    But we’ll have to use more carbon emitting energy which will destroy the planet! Unlike in the 70s, where we had super expensive carbon emitting energy which was destroying budgets, thus the windows that don’t open.

  2. Ezra says:

    Isn’t there something called the CDC who was supposed to figure all this out well in advance? Had plans drawn carefully calculated in advance, the whole set up ready to at a moments notice?

  3. Paul from Canada says:

    This is something I have been saying for some time. Our public health officials have forgotten how to do the basics. We have issues with MRSA and C-Difficlile in hospitals all over the world. We are so used to having antibiotics that work that we have forgotten what it was like when we did not.

    The son of the President of the United States in, I think, the 20′s or 30′s (Grover Cleveland?), died of septicemia from a blister he got playing tennis.

    I remember getting my smallpox vaccination as a little kid. They had set up a big marquee tent at the town hall. My mom took me down, we lined up, got our scratch and a card.

    Polio vaccination happened very quickly and efficiently at school back in the day. No fuss, no muss, van shows up, kids line up, pink liquid on a sugar cube and records filled out, all in a couple of days, over the whole town, country wide.

    Covid vaccine is a little more complicated, requiring complex refrigeration, but even so, we aught to be able to do it universally, like we used to, in weeks, not in months (or up here in Canada, looks like it might be years!). Why a first world country can’t get licensed production set up, and mass distribution done immediately is beyond me.

    Basic hospital hygiene, proper use of quarantine and contact tracing, appropriate use of antibiotics all seem to be known about, but not properly practiced anymore.

  4. Kirk says:

    I’ve mentioned the guy I knew who’d worked at USAMRIID back in the late 1990s/early 2000s.

    One of the fascinating things he talked about was hospital design, and how we were screwing the pooch with it all. They had, you see, just gotten done with replacing the old Madigan Army Hospital with the new version, and that was a highly modern tower-style affair, with all the bells and whistles. The hospital it replaced was one of the old-style single-level jobs with separate buildings for each ward, spread out over acres and acres with a maze of ramps and connecting corridors.

    The point he made about the whole thing was that the old style of hospital had been built that way for very good reasons, and that those reasons had to do with contagion and disease transmission. The new style of hospital that came in with the advent of antibiotics were designed with the theory that there were no infectious diseases we could not put a stop to with a dose of antibiotics…

    Which was a theory he found really short-sighted and laughable. This was a guy who literally used to play games designing diseases, and then gaming out how to control them. His take on the new hospital was “Looks cool, stupid design…”, and he’d lay out pages and pages of reasons why the old-school ideas still had merit. Not the least of which was isolation and the ability to get fresh air into each ward, along with the possibility of literally burning out contaminated wards without losing the entire hospital. At the time, there was this MRSA incident in the news, and he laid out why the modern hospital design more-or-less made things like that nearly impossible to eradicate, while with the old ones, you could afford to lose a few wards to contamination you couldn’t deal with short of incinerating the building. Try that with a multi-million dollar tower block hospital…

    It was interesting to get him talking with our Engineer officers, because they’d cross-fertilize about the whole history of field hospitals and garrison hospitals, along with some really fascinating trivia about it all. The new-style hospitals are going to bite us all in the ass if they ever get contaminated with something like a really virulent Ebola-style virus, because you’re going to have to write the entire structure off and then deal with dismantling it in situ while your workers are encased in biohazard outfits. In the old-school system, with the hospital laid out on the ground over several acres, if you lost a ward to contamination? All you did was wall it off, and call it good until it was feasible to incinerate the structure in place.

    The old-timers were not necessarily stupid; it may well be that the stupid ones are the people who counted on “no virulent disease we can’t control” when designing and building new hospitals.

  5. Paul from Canada says:


    Yes, exactly.

    Old hospitals were designed when we didn’t have antibiotics and we needed to be serious and effective in our hygiene. Now it is all about cost and “efficiency”.

    So you have central air-conditioning and heating because it is cheaper and more energy efficient. You also get the current epidemic of hotel bedbugs for the same reason. Instead of practically boiling the laundry, we use less water and cooler water, to “save the planet”.

    You get things like surfaces picked for cost effectiveness, not ease of cleaning. There is a reason old schools and hospitals all had polished terrazzo floors. It was because you could bleach and/or steam the bejeezuz out of them without damaging them. Try that with rubber tiles or vinyl sheet flooring.

    I have been predicting for years that if we are not really careful, we will get not just a few things becoming “antibiotic resistant”, but a number of lethal things that become antibiotic immune, and we will have to get used to dying of things like infected blisters and insect bites again.

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