Though the pandemic exposed many societal defects that contributed to global suffering, the root cause of failure is that WHO, and other international public health authorities were unwilling to accept, and publicly declare, despite evidence available early on, that Covid-19 is an airborne disease.
Twenty-three months later, a Christmas eve gift to the world: WHO finally, though without penance for their “Original Sin”, accept and quietly communicate this set of facts.
The refusal to give up on belief in a 100-year-old fallacy – that respiratory disease transmission occurs only by droplets and contact – is now a story told in both the lay press and scientific publications. While TB and measles, from the 1960s onwards, were accepted as airborne, other common diseases, including influenza, and most recently, Covid-19 were not.
Because Covid is airborne and not transmitted only at short range (2m or less) by droplets, or “spray”, from coughs and sneezes, we have “superspreading” events where multiple people in the same indoor space all become infected, not just those in close proximity to an infectious person.
Covid is very rarely transmitted by contact. Obsessive handwashing is of little value in Covid prevention, though clean hands prevent other infections.
Accepting that Covid is airborne, i.e. predominantly spread, at both short and long range (many metres), by aerosols that float in the air, would have lead to effective action, including the two key, effective non-pharmaceutical responses that if done intensively and collectively, for just a few weeks, might have prevented spread and avoided extreme action (lockdowns). Wearing well-fitted masks (no gaps between face and mask) made of proper filtration material wherever people gather close together indoors, and ensuring adequate ventilation (fresh air) in those same venues. With enough fresh air to disperse the virus, superspreading does not occur. No superspreading, no pandemic.
By contrast, the root cause failure lead to adoption of useless, expensive and distracting interventions (“hygiene theatre”) e.g. fogging, deep cleaning, and fanatical sanitising of surfaces, and bans on all gatherings, even outdoors, much of which persist to this day.
While the early lockdowns achieved physical distancing, thus slowing disease spread, doing so repetitively and without attention to the root cause created enormous social and economic cost. The ineffectiveness and cost of misguided action lead to opposition, massive levels of mistrust, conspiracy theories, the embrace of ineffective therapies (ivermectin, hydroxychloroquine, etc.) and, critically, to resistance or rejection of the vaccines which prevent hospitalisation and death (vaccination) that became available only a year later.
The way forward was not shrouded in mystery, or due to lack of knowledge about the new virus. Public health and infectious disease establishments failed to consider guidance from engineers, and aerosol scientists, insisted on a particular kind of evidence, and failed to consider the cost of inaction.
The engineers and scientists quickly provided robust insights into how Covid spreads (indoors, via aerosols) and urged appropriate action, but were ignored. Like Galileo at the Vatican, but with more catastrophic results, authorities refused, month after month to change course. Doing so would perhaps have been perceived as a threat to their authority, credibility and power.
One of their claims was, insufficient evidence. Randomised clinical trials are the gold standard of evidence-based medicine, essential for judging specific therapies (e.g., drugs or vaccines) but less useful for assessing “complex” interventions like mask wearing or ventilation during a pandemic. RCTs are not, in this circumstance, a stronger form of evidence than physical laws, repeated experiments and observations, the kind used by engineers to build bridges and skyscrapers that don’t fall down.
Mask-wearing policy exemplifies how the disaster evolved. WHO came out early against mask use by the general public, and advised limiting use of more effective ones (N95 or equivalent) to so-called “aerosol-generating procedures” (AGPs), such as intubation.
Aerosol scientists and engineers demonstrated how aerosols spread and the protection from properly fitted masks made of high-quality filter material. They also showed that AGPs generate less aerosol than talking, shouting or singing.
The public health establishment cited lack of randomised trials. They failed to realise that absence of evidence (large, adequately powered trials) is not conclusive evidence of absence. Even with uncertainty about how Covid-19 was spread, they could have erred on the side of caution, advising the minimum risk interventions of widespread mask wearing and progression to masks that block 90-95% of aerosols, as soon as there was supply, as did some Asian countries who set their own course of action much more successfully.
Another terrible consequence: exhaustion of health care systems and their workforce called upon repeatedly to deal with Covid, along with escalating levels of unaddressed non-Covid health burden, and the threat to their own physical and mental health. Severe effects on non-Covid-related health care caused countless additional deaths and harm.
SA guidelines published by a group of professionals in October 2021 recommend the use of high quality masks (“respirators”) by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who have not yet been clinically evaluated, or are thought or known to have TB and/or COVID-19 or other respiratory infections. These same masks, which cost no more than a dollar or two, should be available to the public. In their updated guidelines, WHO, still a step behind, allow for more protective masks but based on “health workers’ values and preferences and on their perception of what offers the highest protection possible”. They still refer to aerosol generating procedures.
Concern about public fear and panic might have played a part in the reluctance of public health and other institutions to take a different position. Governments and employers are obliged to create safe working environments (e.g., N95 masks) and improve ventilation systems that can clear the air of airborne virus. The high perceived cost of compliance with these interventions went with refusal to shift responsibility (and potentially, legal liability) from individuals to institutions. Easier to point to individual human failings, but inaction resulted in trillions of dollars of lost economic activity, and millions of jobs eliminated.
South Africa’s pandemic response has had many failures but within 3 months local scientists described Covid-19’s airborne disease mechanism and rational action. Sadly, however, the current approach by government continues to generate harm and cost. Communication is ineffective (thanks to Minister “Digital Vibes” Mkhize) and decision-making processes are opaque. We need repeated, clear, public explanation to dispel myths and clarify how Covid is transmitted. Media briefings and other public fora, with scientists in the communication team, should respond to concerns and questions to help stem the massive tide of misinformation, share uncertainties, concede past errors, and make corrections. Even as we look hopefully at declining omicron case numbers and relatively low hospital admission rates, we need quick and effective responses to many important questions, armed with WHO’s Christmas offering and the facts about how Covid-19, an airborne disease, is actually spread. DM
OPEN QUESTIONS FOR POLICY-MAKERS
- Why are boosters being delayed?
- Why are rapid tests for self-testing not available?
- How do we balance loss of health with protection of the health system, protection of the economy, and mitigation against the social effects of restrictions?
- How do we increase vaccination rates? Why is it still necessary?
- What have we learned from our delayed and ineffective vaccination drive?
- How will we gain access to new and effective oral treatments for Covid?
- What can be done to improve ventilation of public indoor spaces to address the long-standing TB epidemic in our country?
- How do we support vital businesses that continue to suffer?
- How do we get a high-quality mask into the hands of every South African to protect against Covid-19 – and TB? How do we make every taxi and other form of public transport safer?
- Why should quarantine be discontinued and what are the unintended effects of doing so?