yes, it’s the system

Only in the past month have public health authorities in Canada acknowledged that SARS-CoV-2 is primarily spread through the air, after more than a year of prevaricating by ‘Droplet Dogmatics’ in face of the evidence.

“Since March 2020, Ontario [Province of Canada] public health guidelines have stated that droplet precautions are adequate to guard against COVID-19 transmission. According to the province, airborne precautions, such as N95 masks, are needed only by those performing aerosol-generating procedures, such as intubating a patient [in June 2021].” —CBC 2021-06-20

COVID-19 is an airborne disease. Canada’s Chief Public Health Officer only publicly acknowledged airborne transmission this November. But many protocols to control fomite transmission continue, such as plexiglass dividers and surface washing conveyor belts in supermarkets.

In view of overwhelming evidence, our structures — workplaces, schools, eating establishments — still do not change to adapt to the evidence. Peter Drucker is attributed for the saying that ‘Culture eats strategy for breakfast’. [What Drucker really said was, “Culture—no matter how defined—is singularly persistent.”] Or perhaps Robbie Burns said it best when considering what happens to our ‘best laid schemes’.

But Mousie, thou art no thy-lane,
In proving foresight may be vain:
The best laid schemes o’ Mice an’ Men
Gang aft agley,
An’ lea’e us nought but grief an’ pain,
For promis’d joy!
—To a Mouse

Helmuth von Moltke said that, “No plan survives contact with the enemy”. And whatever plans we made to deal with the assumed fomite transmission of this virus have not survived either. Admitting this is the first step in taking action.

“Every policy that is predicated on a fomite/splash risk to the exclusion of airborne inhaled aerosols is simply inept and not fit for purpose. Start again with the correct foundation of transmission risk, build from there and the structure will be robust.” —@MicroLabDoc

But we have to look further back in time to when we understood that fresh air is a prime determinant of public health. Florence Nightingale promoted the importance of clean air, “The very first canon of nursing … is this: to keep the air [the patient] breathes as pure as the external air, without chilling him.” At one time, our hospitals were designed for air flow, but we became enamoured with technology and now have hospitals where contaminated air is recirculated and windows do not open. Our techno-centric healthcare systems have lost touch with the reality of pandemics.

Like all crises that reveal cracks in the system, the pandemic has prompted a public reckoning with the role of buildings in shaping our health. Recent reporting is waking up to the crisis of breathability in buildings, raising questions about our dependence on mechanical systems and the lack of access to fresh, natural air. Why are so many buildings filled with inoperable windows? How did we not foresee the dangers of creating an airtight seal around entire city blocks? Is it really acceptable that our built surroundings are entirely dependent on evermore complex mechanical systems that pollute the environment and, if they should fail, prevent us from breathing? —The secret to hospital design was solved 150 years ago. Why did we ignore it?

—

Forget your perfect offering
There is a crack
A crack in everything
That’s how the light gets in.

—Leonard Cohen (1992) Anthem

Yes, it’s the system, stupid. First we have to understand the system, and then change the underlying foundations. Even penalizing those in change or replacing them will not change any system from which they emerged.

In 2018 I wrote that we need to change the system, not the leader and create organizations based on diversity, learning, and trust so they are better prepared to hack uncertainty and hedge risks, especially in crises like pandemics. Leaders can then emerge who have access to a diverse range of ideas and opinions — such as epidemiologists learning from engineers — from which they can learn. For example, at the WHO and at the national public health policy boards, aerosol science was ignore by medical experts, “Aerosol scientists—typically, chemists, and engineers—representing the heterodoxy were systematically excluded from key decision-making networks and committees.” —Orthodoxy, illusio, and playing the scientific game

Leaders must influence through their reputation, not position, to make their networks and communities stronger, so that we can all keep on learning. As Rachel Happe says, “Control is for amateurs”. Today, in a networked and tightly integrated world — work is learning, and learning is the work.

Image: Leyla Acaroglu — Read more: Systems Thinking