Business, Ventilation, and Health—Can We Have Them All?

In his opening comments at the 2022 White House Summit on Indoor Air Quality, Ashish Jha, MD, MPH, the White House’s COVID-19 response coordinator, reflected on the history of public health advances. Jha explained that when waterborne pathogens were understood, “we learned that you could of course boil your water and make it safer, but the policy solution was not everybody should boil their water all the time.” Instead, a series of policy changes and systematic engineering efforts improved the healthfulness and safety of drinking water, curbing the spread of the gastrointestinal ailments that once dominated mortality charts. Jha pivoted from this public health achievement to say, “Indoor air is the next frontier when it comes to thinking about public health.”¹

Indoor air is not a new topic for public health. Jha’s comments echoed New York City physician and public health advocate John Hoskins Griscom Jr., who opened his 1852 public lecture on ventilation by talking about water safety. According to the New York Times:

Dr. Griscom commenced his lecture by observing that the importance of pure air was not so much studied as it ought to be, or it would be the care of persons generally to obtain as much purity in the atmosphere of their dwellings as possible. The City of New-York had spent fifteen million dollars in endeavoring to obtain pure water, but this was not more necessary to health and life than was pure air.^2(p1)

Griscom frequently compared the city’s immense expenditures to secure safe drinking water (more than $600 million in today’s currency) with its failure to invest in ventilation. If New York City’s citizens wanted to protect health, Griscom argued, they should invest in both water and air quality. For Griscom, as for many other 19th-century sanitarians, improving the whole environment was the best method for preventing disease. Yet governments and business leaders invested in environmental changes that would directly benefit businesses. Many businesses benefited from increased water supplies, but sewer systems that carried away excess water and human waste lagged behind because their “revenue-generating potential was limited.”^3(p62) Sewer systems curbed the spread of cholera and gastrointestinal illnesses but were adopted slowly because sewers were not directly profitable.

Is the profit motive why, in the face of respiratory diseases that are transmitted through the air we breathe, so many ventilation proponents emphasize outcomes other than disease prevention? As LaFay and Sampson document in “Ventilation and Public Health: A Fraught History” (p. 798 in this issue of AJPH), many of the recent justifications for improving ventilation have emphasized increased worker productivity and student performance. Both were talking points at the White House Summit.

LaFay and Sampson’s history of ventilation efforts demonstrates how leaving a public health necessity to private development has created health inequities that follow social inequality. Ship ventilation did not protect enslaved men and women from the deadly effects of overcrowding, poor nutrition, and abuse. Similarly, windows and air shafts could not combat the vermin and fires that killed tenement dwellers. Nor could HVAC (heating, ventilation, and air-conditioning) systems combat the neurologic effects of chemicals emitted from new building materials in postwar airtight high-rise offices. Ventilation and indoor air quality, when removed from the comprehensive environmental improvements that 19th-century sanitarians sought, have not prevented illness and death.

These failures of ventilation do not mean that we should abandon the effort. Instead, LaFay and Sampson argue, ventilation should be integrated into social and health policies. Better ventilation will curb the spread of respiratory diseases. In addition, ventilation should be pursued through the same avenues that gave modern society safe drinking water.

In his opening comments at the White House Summit, Jha demonstrates his understanding of the history of public health advances, but he ignores that laws and regulations created our healthy water supply. The White House Summit on Indoor Air Quality did not launch equivalent policy changes and systematic engineering efforts to improve the safety of the air that those who live in the United States inhale in homes and public buildings. Instead, the summit promoted the Environmental Protection Agency’s Clean Air in Buildings Challenge, a voluntary “pledge opportunity” that invites businesses and building owners to commit publicly to improving indoor air quality.⁴ The challenge is the latest in a long history of public health initiatives that are business friendly.

When Griscom advocated ventilation in 19th-century New York City, he also learned to be business friendly. This meant focusing his ire on sublandlords rather than the landowners who were responsible for the exploitative real estate system in which buildings were overcrowded and undermaintained.⁵

New York City tried to improve ventilation through a series of Tenement House Acts passed between 1867 and 1901 that stipulated room size, number of windows, and the proportion of the lot that buildings could occupy. Rather than adhere to these regulations, landowners maximized rentable living space by adopting architect James Ware’s “dumbbell tenement.” Even when public health regulations have tried to curb businesses in favor of health, businesspeople have found ways to make money, often at the expense of public health.

Unlike the history of ventilation, the history of the water supply in the United States is thick with laws, ordinances, and regulations. Early public health departments tested water and published reports that led to standards and regulations. Massachusetts passed laws preventing pollution and permitting experiments on water purification in the 1880s.⁶ In the early 20th century, as it became evident that filtration could remove bacteria, cities adopted filtration systems.

Since the creation of the Environmental Protection Agency in 1974, the United States has had national standards that protect public drinking water and its sources.⁷ Economists have found that the Clean Water Act and the Safe Drinking Water Act have been effective in reducing water pollution.⁸ None of these standards has been promoted as challenges. Instead, the history of water supplies in the United States is one of engineering efforts, scientific analyses, and legal regulations with which individuals and businesses have had to comply.

Should we want to learn from the past, we need to know not only what changes have improved public health but also how those changes were implemented. Laws and regulations have accomplished more than voluntary appeals to business leaders and building owners.