Of the three main modes of infection for flu — transmission by large droplets, transmission by tiny suspended aerosols, transmission via inanimate objects (also called fomites) — it is the last that is the least certain but garners the most attention in the form of hand hygiene, disinfectants and now, fear of magazines and toys in emergency department waiting rooms and acute-care clinics in Canada. Here’s the lede from an article in the Montreal-Gazette:
All magazines and toys should be removed from emergency department waiting rooms and acute-care clinics to reduce exposure to human swine flu, federal health officials are recommending. (Saron Kirkey, CanWest via Montreal Gazette [hat tip tweets JuliaS1573 RT @themediaisdyin]
The Guidance from the Canadian Federal authorities includes measures aimed at the other modes of infection, too: masks, separate triage and waiting areas for those with respiratory signs and symptoms, etc., but it was the toys and magazines that captured the lede (the first paragraph, in newspaper talk). And on reading it, the first thing that popped into my head was The Velveteen Rabbit.
The Velveteen Rabbit was a children’s book, written in 1922. I read it when I was an adult because of an interest in the history of public health during the Progressive Era, but it remains in print and I’m guessing a number of folks out there have read it. Here’s the plot, given in Wikipedia:
A boy receives a Velveteen Rabbit for Christmas. The Velveteen Rabbit is snubbed by other more expensive or mechanical toys, the latter of which fancy themselves real. One day while talking with the Skin Horse, the Rabbit learns that a toy becomes real if its owner really and truly loves it.
When the boy’s china dog is misplaced, the Velveteen Rabbit is given to the boy as a quick replacement by the maid. The Velveteen Rabbit soon takes his place as the boy’s constant companion. The Rabbit becomes shabbier, but the boy loves him no matter what. In the woods near the boy’s home, the Velveteen Rabbit meets actual rabbits, and learns about the differences between himself and the real rabbits when the real rabbits prove he is not real by his inability to hop or jump or his shedding fur.
The Velveteen Rabbit’s companionship with the boy lasts until the boy falls ill with scarlet fever. The boy becomes too ill to play for a very long time; upon his recovery, he is sent to the seaside on doctor’s orders. The boy wishes to take the Rabbit with him, but his doctor forbids him to take the germ-laden toy and says it must be burned along with all the nursery toys in order to disinfect the nursery. The boy is given a new plush rabbit with glass eyes and is so excited about the trip to the seaside that he forgets his old Velveteen Rabbit. (Velveteen Rabbit entry, Wikipedia)
Sigh. OK, it doesn’t end so sadly Before being burned, the Rabbit sheds a real tear which brings the Magic Fairy who turns him/her into a real rabbit which then goes hopping off into the woods. Etc. What interests me is that the response 90 years later isn’t much different. Public health at the time the book was written was in a period of transition. Charles V. Chapin’s book, The Sources and Modes of Infection, had come out in 1910 and expressed the heretical opinion that the main sources of infection in people were other people, not the environment. He used scarlet fever as an example of where fomites weren’t the way kids got sick from that disease. By the time the second edition came out there had been a dramatic reversal in public health science in Chapin’s direction. It is not a coincidence that this occurred at a time of tremendous anxiety about immigrants, anarchists, socialists, and other “dangerous people.” In medicine this became crystalized in the image of Typhoid Mary Mallon, an Irish immigrant cook who was a disease carrier that infected the upper class families she worked for. Just at the point where the “environment,” in the form of the Velveteen Rabbit, was tagged as the source of disease, public health was about to abandon it and concentrate on society’s most marginal people, in keeping with the Zeitgeist. In doing this public health voluntarily but disastrously placed themselves under the thumb of a medical profession, guided by a politically re-invigorated American Medical Association and its state and county affiliates (a bit more on this here).
We are at another cusp point in public health, with forces pushing us in opposite directions. Phantom socialists and terrorists are again afoot but so is a new concern for the environment. When it comes to whether fomites are a significant cause of flu transmission there are important open scientific questions, but the issue of inanimate objects versus dangerous people also has other resonances that aren’t scientific and reinforce or interfere with altogether different questions, often with political consequences.
Which is why when I read about removing toys from Emergency Departments I think of The Velveteen Rabbit.