The “Best of All Breathing”?

Novelist William Faulkner’s magnificent phrase applies to far fewer people than it should.¹ Historians are partly responsible for that. Maybe they can help to fix it.

LaFay and Sampson (p. 798) in this issue of AJPH rightly call air’s status in public health history “fraught.” Concern with occasional adventitious constituents has been hard to translate into sensibilities about exposure or prophylaxis. For arthropod vectors or for water, it is easier. A leader in 19th-century medical hygiene in the United Kingdom, John Snow’s famous map lets us follow water from a single well to containers, guts, excretions, and new cholera cases. But air? Molecules leap from surfaces, are exuded by beings, go up chimneys. They ignore channels, never find sinks. Some harm health, but dodging them is hard when you cannot see the medium or what it carries. And airs have incidental properties affecting well-being: temperature, moisture, and movement. I know when water wets, but air always aerates.² No one gets away with the “I don’t inhale” excuse for long. And if we live under a sea of air, surely we should be swimming. A mysterious “air handler” lives in the furnace. Good thing—I can’t handle air.

Although students introduced to Hippocrates’s Airs, Waters, Places usually fixate on the water, airs have loomed much larger in health anxieties; we need only think of mal-air-ia, which was a geographic descriptor before becoming a disease.

Historians, sometimes using “miasma” to stand in for bad science, have been coconspirators with consolidators of professional public health in the relegation of “air” to “error.” Emphasis on acute diseases and visible public undertakings with big payoffs helped public health to establish itself and garner public support but also shaped the field in terms of core and periphery.³ Had architects, urban planners, or engineers led the professionalization, matters of air would have been more central, yet the shape of public health (and of those professions) would be different.

But it is hard to respond rationally to what you cannot see. Current air-mindedness reflects the shock of COVID-19. Who knew that sharing air with other droplet-dropping or aerosol-emitting exhalers showing no stigmata of danger could kill you? Or that you could kill them? Air hygiene often must operate in the realm of imagination simply because we cannot perceive air quality. Early in the pandemic, before the call to mask, I handled my fear by doubling over a welder’s hat and sewing on an elastic band. It was snug (I could barely breathe), and knowing that welders worked in dangerous airs reassured me, if unreasonably. To the micron-minded, my efforts were primitive and pathetic, yet as many of us discovered, the sleek, sharp, N95s did not eliminate anxiety; they might have magnified it. For me, doing my best put my mind at ease.

Air anxiety is not new. Go back two millennia and we find air as the first of Greco-Roman physician Galen’s six things nonnatural, factors physicians adjust to manage health. “You need a change of air,” they say.⁴

Or pop ahead to the 1740s to John Pringle, expert on army air. He confronted a problem that persists: is outdoor air better than indoor? He worried about soldiers sleeping on damp ground but more about “effluvia” from sick and wounded bodies in hospitals.⁵ The great fix of moving air, ventilation, was often unpopular. Laypersons, having “caught a draft,” would blanket themselves in closed spaces, but Pringle would have the draft catch the patient. Later one hears of medics breaking windows to expel the fetid air and expose the ill body to a cleansing wind. Nursing manuals would extol the sash window, which must be pulled down from the top and up from the bottom.^6,7 My parents, raised to view fresh air as a panacea, insisted that my bedroom window be open a crack even on January nights with temperatures reaching −30° Fahrenheit. (Later, amid the energy crisis, I would turn to the opposite extreme, a fanatic with tape and caulk, futilely seeking out cracks.)

Air paranoia peaked in the mid-19th–century heyday of English sanitarianism. The great undertaking of the hydraulic city (good water in, wastes washed out) began as a way to fix the air infected with all that might stink. The greatest paranoia was with reflux: what went down the sewers might bubble back as imperceptible “sewer gas” unless trapped by a water seal or sent harmlessly over the roofs by a vent pipe. Want a challenging historical project? Try mastering Victorian trap design debates.⁸ Acceptance of the “zymotic” diseases (those presumed to result from decay) as spread by ingestion rather than inhalation was slow, both in public health science and lay sensibility, but was a hallmark of the progress associated with John Snow and German microbiologist Robert Koch.

At the same time, a sanitarian public health often marginalized not only respiratory infections, most conspicuously tuberculosis, but indoor matters: dwellings and workplaces. Often these were public, yet not unambiguously public health, matters. Not only were sewers public in a way that sleeping spaces were not, the latter were more clearly subject to the invidious tradeoffs at the nexus of lifeboat ethics and slave ship economics that Karl Marx recognized: the equating of space with life and money.⁹

Later 19th-century campaigns to regulate occupancy had mixed motivations. Worries about morality and generic concern with contagion are more prominent, but ventilation, sometimes conceived as adequate respiration, is the proxy susceptible to regulation: inspectors unable to measure throughput might insist on windows or on minimum cubic feet per person; yet in enforcing occupancy limits in the name of public health, they neglected to confront the question of which person is the extra who must leave the lifeboat, if only to climb into another.^10,11

Public health was no match for a labor market requiring people to live near their work. Cold exacerbated crowdedness. A stove must have a draft, but better to keep all heat, even if it means keeping exhaust gases. Surely there were many deaths from CO, though its toxicity was elucidated only in 1856.¹² Workplaces brought similar issues, with the addition of heat, dust, and trade toxins and ventilation often seen as interfering with quality control.

We may be surprised that ventilation acquired any priority. Economies favored filling space with blocks of building. Even so, windows would be for opening as well as light, and ventilation would become standard in urban building design. Urban planners would straighten streets to facilitate the cleansing wind. They would build parks. We find such agendas in late 19th-century public health manuals; nonetheless, around 1900, the “new” case and germ–tracking public health generally left them as someone else’s business.¹³ That would carry over to the new technology of air conditioning. Heat emergencies requiring cooling stations are becoming common, yet in public health history air conditioning registers mainly as the medium of legionnaires disease.

The United Nations recognizes rights to water and sanitation. But air? Inequalities exist; they register as harm to health. Are they violations of rights? Indoor and outdoor airs are regulated by governments or standard-setting professional bodies. In the wake of COVID-19 the World Health Organization has taken up the issue.¹⁴ Still, concepts of fair breathing will ultimately require changed sensibilities. Had COVID-19 been a fecal–oral disease, concerted action would have been much easier. The golden rule and 18th-century philosopher Immanuel Kant’s categorical imperative work for excretions. Perhaps they might work for exhalations, letting us give to one another more gifts of good air.