An Official Smoking Gun on #CovidIsAirborne Denial by Hospitals Because They Didn’t Want to Spend Money Changing Their Physical Plant

By Lambert Strether of Corrente.

“Something is rotten in the state of Denmark.” –William Shakespear, Hamlet, Act I, Scene 4.

So far, in the United States, we have been limited to teasing out the motivations for official denial or resistance to the aerosol/airborne transmission paradigm in hospital infection control from vague hints in published documents; in fact, from footnotes in official documents. To the best of my knowledge — and I do try to keep track — we’ve never had an official come right out and say “We’re not dealing with airborne transmission in hospitals because that would cost too much money.” Well, now one has. Granted, the smoking gun is in Denmark. In this short and sweet post, I’ll contextualize and present a Twitter thread where the smoking gun official appears.

To be fair, Eric Feigl-Ding amplified the thread, although I had flagged it previously in my meanderings through the aerosol community:

However, I am not the sort of person to be satisfied with context-free images of tweets, especially where I don’t know the players. So herewith the context.

Here are the protagonists in the thread amplified by Feigl-Ding (as I have excerpted and translated it)[1]. There are four laypeople:

1) Fritze Heisterberg @fcandersen (joined 2011);

2) Marianne Ernø @ErnoeMarianne (2011);

3) Christina Brøndsholm Andersen @CBroendsholmA (2017), a choregrapher;

4) Peter Favrholdt @pfavr (2009), a cookware entrepreneur.

(I give the dates they joined to show we’re not dealing with trolls. Also, my Danish search skills are bad, so I can’t dope out anything about Heisterberg and Ernø beyond their Twitter profiles.

Finally, there is:

5) Stinus Lindgreen @stinuslindgreen (2009), a Danish scientist and politician, and a member of the Folketing [Parliament] for the Social Liberal Party. More importantly for our purposes, Lindgreen is chair of Denmark’s Epidemic Committee[2], hence an elected, hence also a reasonably high official in a position to speak with authority about the inner workings of government decision-making in the pandemic.

The thread takes place during and/or in response to a one-day workshop on aerosols at Denmark’s Statens Serum Institut on October 4, 2020. Lindgreen attended, and in his first tweet below supplies a shot of the schedule (aerosol smitte/aerosol infection”) and a shot of a presenter and venue:

And now to the interesting part: The transcript. What we have here, it feels like to me, is a ordinary citizens badgering one of their electeds about aerosols, and cornering him into some interesting admissions. (The population of Denmark is a bit under six million, a scale which permits such a thing.[3]) The original Tweets, in Danish, are italic. Google translations follow in Roman. Lindgreen’s name is bold. His two smoking guns are underlined.

Fritze Heisterberg / @fcandersen Oct 4

Øj jeg gad godt være en flue på væggen og høre @AKiversen fortælle om aerosolsmitte og den uenighed @stinuslindgreen mener der var om det emne…det er alligevel imponerende den uenighed fortsætter!

Oh, I’d love to be a fly on the wall and hear @AKiversen talk about aerosol contamination and the disagreement @stinuslindgreen thinks there was on that topic…it’s still impressive that the disagreement continues!

Stinus Lindgreen / @stinuslindgreen Oct 4

Efter den officielle åbning af Folketinget sidder jeg nu på @SSI_dk til en hel dags workshop om bekæmpelse af aerosolsmitte. Indtil videre rigtig spændende indlæg om udluftning, filtrering og smitterisiko. #dkpol #sundpol

After the official opening of the Folketinget, I am now sitting at @SSI_dk for a full-day workshop on combating aerosol infection. So far, really interesting posts about ventilation, filtration and risk of infection. #dkpol #sundpol

Stinus Lindgreen / @stinuslindgreen Oct 4

Jeg sagde ikke, der var uenighed om, hvorvidt smitten er luftbåren eller ej. Det handlede mere om balancer i håndteringen.

I didn’t say there was disagreement about whether the infection is airborne or not. It was more about balance in handling.

Fritze Heisterberg / @fcandersen Oct 4

Hvilken smitte præcist mener du for pt omtales Covid-19 ikke som luftbåren smitte i dansk regi/udadtil til danskerne!

Og tak for præcisering…ville godt have været der alligevel…

Which infection exactly do you mean because currently Covid-19 is not referred to as an airborne infection under Danish auspices/externally to the Danes!

And thanks for the clarification…would have been there anyway…

Stinus Lindgreen / @stinuslindgreen Oct 4

Det er en strid om ord – også i denne forsamling. Men enighed om at smitten sker via den luft, vi deler.

It is a dispute about words – also in this assembly. But agreement that the infection occurs via the air we share.

Fritze Heisterberg / @fcandersen Oct 4

Overfor befolkningen er det ærligtalt ikke ok!

Og det er jo ikke bare en strid på ord det handler jo også om hvordan der handles i hverdagen.

For man kan ikke undgå luftbåren smitte med håndvask eller?

In front of the population, it is honestly not ok!

And it’s not just a dispute about words, it’s also about how you act in everyday life.

Because you can’t avoid airborne infection with hand washing, can you?

Stinus Lindgreen / @stinuslindgreen Oct 4

Det handler mere om, hvad det betyder for praktikken på hospitaler.

.

Above is Smoking Gun #1. Apparently, there’s some “practice” more important than protecting patients from a highly infectious airborne disease. (I’d speculate this is Hospital Infection Control, in hospitals and at WHO, but I can’t back that up yet.)

Fritze Heisterberg / @fcandersen Oct 4

Men som sagt det handler ikke bare om 🏥. Men om smitteforbyggelse generelt hele vejen rundt i samfundet og eks offtenlig transport.

En del af smitteforbyggelsen er i [Denmark flag] også man for fortalt hvordan covid-19 og influenza smitter. For pt bliver der råbt håndvask før udluftning!

But as I said, it’s not just about 🏥. But about infection prevention in general throughout society and e.g. public transport.

Part of infection prevention is in [Denmark flag] also telling how covid-19 and influenza are contagious. For now, hand washing before venting is being shouted at!

Stinus Lindgreen / @stinuslindgreen Oct 4

Betegnelsen “luftbåren” betyder i dansk kontekst noget for, hvilke krav det stilles til indretning af isolationsstuer osv. Det var pointen. Konsekvensen af de mudrede udmeldinger kender vi.

In the Danish context, the term “airborne” means something for the requirements for the design of isolation rooms, etc. That was the point. We know the consequences of the muddy announcements.

Peter Favrholdt / @pfavr Oct 5

Det betyder også meget for hvordan vi indretter os udenfor hospitalerne. Udluftning, HEPA, eller man kan gå udendørs. Hvad med skoler?

It also means a lot to how we arrange ourselves outside the hospitals. Ventilation, HEPA, or you can go outdoors. What about schools?

Fritze Heisterberg / @fcandersen Oct 5

Præcis!

Exactly!

Stinus Lindgreen / @stinuslindgreen Oct 4

Men derudover er jeg ikke uenig med dig. Jeg har rejst spørgsmålet utallige gange, og det tog som bekendt lang tid, før udluftning blev en del af de officielle anbefalinger.

But other than that, I don’t disagree with you. .

Seems familiar!

Christina Brøndsholm Andersen / @CBroendsholmA Oct 4

Det er ikke godt nok næsten 3 år inde i pandemien. De danske sundhedsmyndigheder må kommunikere klart ud at den primære smittevej er luftbåren og at den bedste beskyttelse er ventilation, HEPA luftrensere og FFP2/3 masker. Danskerne spritter fortsat hænder mod en luftbåren virus

It is not good enough almost 3 years into the pandemic. The Danish health authorities must communicate clearly that the primary route of infection is airborne and that the best protection is ventilation, HEPA air purifiers and FFP2/3 masks. The Danes continue to spread their hands against an airborne virus

Marianne Ernø / @ErnoeMarianne Oct 4

Sgu da ikke bare på hospitaler!! Har du ingenting forstået?

Don’t just go to hospitals!! Didn’t you understand anything?

Stinus Lindgreen / @stinuslindgreen Oct 4

Jeg prøver bare at forklare, hvorfor man ikke brugte denne betegnelse i Danmark – fordi det ville have konsekvenser for indretningen af hospitaler.

I’m just trying to explain why this designation was not used in Denmark – because .

Above is Smoking Gun #2. Health of patients not the first concern of hospitals, apparently.

Fritze Heisterberg / @fcandersen Oct 5

Og @stinuslindgreen der fik vi sat 2 stregner under politik vandt over ordenlig information om smitteveje til borgerne hvilket en som @AKiversen prøver så godt hun kan. Kedeligt du ikke fik hørt hende for hun er en vigtig stemme i formidlingen. Håber, at du læser hendes tweets.

And @stinuslindgreen there we put 2 lines under politics won over proper information about routes of infection to the citizens, which someone like @AKiversen tries her best. Too bad you didn’t get to hear her because she is an important voice in the media. Hope you read her tweets.

Fritze Heisterberg / @fcandersen Oct 5

Det kan jo virkelig bide sig i måsen når man ikke informere ORDENTLIGT om smitte til borgerne hvilket kan have konsekvenser på kort og langsigt!

Oven i vil man ikke tilbyde vaccine til alle og derfor klinger #sundhedforalle meget hult!

It can really backfire when you don’t PROPERLY inform citizens about infection, which can have consequences in the short and long term!

On top of that, they don’t want to offer a vaccine to everyone, and therefore #healthforall sounds very hollow

Christina Brøndsholm Andersen / @CBroendsholmA Oct 4

Og det er heller ikke godt nok næsten 3 år inde i en pandemi med en luftbåren virus at det ikke er obligatorisk at bære masker på hospitaler og andre sundhedssteder som fx læger og vaccinations steder

And it is also not good enough, almost 3 years into a pandemic with an airborne virus, that it is not mandatory to wear masks in hospitals and other healthcare facilities such as doctors and vaccination sites

Christina Brøndsholm Andersen / @CBroendsholmA Oct 5

Dette viser jo med al tydelighed, at @SSTSundhed ikke er i stand til at stå i spidsen for pandemirespons. Det er uetisk og sundhedsmæssigt uforsvarligt af forholde den danske befolkning at #covid19 er luftbåren bare fordi det så blir besværligt på hospitalerne.

This clearly shows that @SSTSundhed is not able to lead the pandemic response. .

Indeed!

* * *
Of course, “layouts” differ by hospital, and I am sure by country and jurisdiction too, depending on regulations, medical practice, culture, etc. However, I think we can make a reasonable speculation about what’s going on. Cook Children’s Checkup Newsroom quotes a few of “the rare remaining physicians who have treated measles.” They descibe the “layouts” of the past and how they changed:

Measles is one of the most contagious diseases known to exist. According to the Centers for Disease Control and Prevention (CDC), the virus can live for up to two hours in the air where an infected person coughed or sneezed. If other people breathe the contaminated air or touch a surface that’s been infected, they risk infection. For this reason, Dr. Hucaby says a doorbell was installed outside of the pediatric clinic where she worked during the outbreak.

“Parents were asked to ring the bell if their child had a fever, with or without other symptoms,” she said. “A nurse would go out into the hallway to look at the patient. .”

Another Cook Children’s physician, Britt Nelson, M.D., remembers a time when seemingly every hospital had an area dedicated to infectious diseases. Dr. Nelson is the medical director of the Physician Network at Cook Children’s, but in the early 1980s he was just starting his career.

“,” said Dr. Nelson. “But as infectious diseases became better controlled, particularly the ones that are so contagious like chicken pox and measles, we didn’t need to have a special ward anymore.”

The reason for the decline in such quarantined areas is simply vaccines.

As is well known, Covid vaccinations don’t prevent transmission. Hence the hospital layouts of today, optimized for the beforetimes, when vaccines were sterilizing and coughing people didn’t infect each other in waiting rooms and hallways, or need to go directly to exam rooms, would need to be changed to prevent airborne transmission (see studies here and here on preventing transmission in anterooms and waiting rooms). I don’t know why Denmark’s hospitals (successfully) fought to keep the airborne paradigm from coming before the public. In this country, I would speculate that private equity — or competion by putative non-profits with private equity-backed competitors — was an important factor. From the Journal of the American College of Radiology, “Private Equity–Backed Hospital Investments and the Impact of the Coronavirus Disease 2019 (COVID-19) Epidemic‘”:

[T]he restrictive nature of the PE business model demands an abundance of short-term profits for success. That, in turn, makes it unlikely that an investment firm in this class would consider the use of alternate longer-term strategies—including solutions that would avoid hurting physicians and other employees, particularly in the middle of a crisis. If a firm is not going to be involved in the investment after 10 years, then it is unlikely that the PE investor will be interested in whether the physician culture at a hospital is destroyed. It is also unlikely that much thought would be given to what happens to patients if a hospital goes bankrupt or is turned into commercial real estate for condominium development. These events during the COVID-19 crisis highlight the limits and risks associated with third-party financial investment in health care. In good times, investors and their portfolio companies can do quite well, but in a stress test like this pandemic, key stakeholders, including patients, physicians, other providers, and their communities, can be significant losers.

Obviously, ownership that wants short-term profits won’t be investing in revising hospital layouts to include special infection wards (not rooms, but wards), new anterooms, or even doorbells. Nor will they encourage any practice that would encourage a demand for such facilities investments. Hence, no masking, since masking provides the strongest possible signal that #CovidIsAirborne.

Returning to the transcript for one moment: It’s really remarkable for an official to let the cat ouf of the bag as Lindgreen did. Somebody from our famously free press should interview him and get more detail. It would be nice of some officials in our country were as forthright as Lindgreen, too.

UPDATE Adding if anybody on this side of the Pond wants to throw the internal deliberations of some Hospital Infection Control Commmittee over the transom, I’d be very interested.

NOTES

[1] I would have used @threadunrollapp, but Twitter isn’t famous for the coherence of its threading, especially when the conversation has a lot of byways, and I couldn’t get it to unroll all the tweets I wanted in sequence. So I created this thread manually.

[2] Apparently, there is an Epidemic Commission (epidemikommissionen), and an Epidemic Committee (epidemiudvalget). The Commission “advises the government on management of the Covid-19 pandemic,” and was also part of a Danish government reorg when Covid broke out:

Responses to contagious disease outbreaks are governed by the Danish Epidemics Act. (Lov om foranstaltninger mod smitsomme sygdomme og andre overførbare sygdomme (Epidemiloven) (LBK 2019-10-01 no. 1026).) On February 27, 2020, Sundheds- og aeldreministern (Danish Minister of Health) added COVID-19 to the list of contagious diseases covered by the law. (LBK 2020-02-27 no. 157.)

On March 12, 2020, the Danish Parliament (Folketinget) passed legislation amending the Epidemics Act using expedited procedures (hastelov). The main change in the law was that it gave the Danish Minister of Health most of the powers that were formerly prescribed to the Epidimikommission (Epidemic Commission), in order to provide for a speedy response [hmm] to COVID-19. Normally, an Epidemic Commission is made up of representatives from the Danish Health Authority, the police, a doctor, a veterinarian, a customs and tax authority representative, a regional hospital representative, a representative from the Danish Emergency Management Agency, and three members from the regional council. (§ 3 LBK 2019-10-01 no. 126.)

What the difference between the Commission and the Committee is I cannot say, my Danish search skills again being insufficient.