Sequestration in medicine: the newest strategy for splitting people up is three centuries old.

Two and a half years into the COVID-19 pandemic, and we have at long last reached a point where, even if the public health concerns have not yet dissipated, the public will for restrictions is all but completely absent.  The CDC, WHO, and FDA may still issue occasional alerts and updates, but the thunk of a stone thrown the lake elicits less of a discernible ripple, not because of any change in the intrinsic qualities of the lake or stone, but because so many others newsmakers are hurling similarly sized stones simultaneously.  In many respects, this is a positive turn of events, because it allows the public to shift focus away from something so polarizing.  The wounding, heated divisions that public health restrictions elicited, almost from the beginning, have begun at last to heal somewhat, leaving visible scar tissue in place.  Many people found that (at least in the US) the state-level restrictions on indoor crowds or the ability to conduct in-person commerce constituted an unreasonable and unjustifiable exercise of police power; still others believe that they were insufficient and too fragmented in this country, resulting in the lack of unified preventive effort that elicited unnecessarily high mortality levels.  It is unlikely we will ever reconcile these dipoles, but at least a sort of middle-ground approach can help the broader public take what we’ve learned upon reassessment after the panic, to institute the more sensible long-term prophylactic solutions: the scar tissue.  Which more or less involves sequestration—a practice that public health authorities have instituted from the start, and, provided it does not impede economic mobility, still seems to enjoy a level of tolerance among the general public.  So long as the intent is to protect the most vulnerable from the already sick—rather than to impede the movement (and thereby punish) the healthy—the public generally deems at least some degree of sequestration as reasonable.

And sequestration is the only explanation for what I encountered recently in a mixed-use office/residential complex in Alexandria, Virginia:

It’s an entrance to Pediatric Associates, exclusively for the noticeably unwell.  And, yes, there’s a counterpart entrance just a few feet away.

So Pediatric Associates effectively sequesters the “sick” and the “well” through discrete entrances.  The business may have initiated this practice long before March 2020, but I did pass by these offices periodically and never noticed it prior to this point.  (I’ll concede that I was not attuned to such a feature prior to COVID-19 lockdowns, and I do vaguely recall seeing such a thing at a clinic during my own childhood.  But now I scout these things like a hawk on the prey—the weirder the better.)

This entrance at Pediatric Associates may not be so weird, but it still seems largely reactive.

The photo above shows how close in proximity the two entrances are from one another, yet they also have separate address numbers (150 and 160), suggesting that Pediatric Associates either leased or purchased two adjacent spaces within this office building, then modified the partitions to give them the right balance between sequestration and unity of function.  I failed to take a photo that fully captures the space between these two entrances, but this nighttime image at least offers a reasonable hint.

Peeking out on the right-hand edge of the frame in deep blue is the reception desk—the primary divider between the sick and well.  It’s not a full wall, and under normal circumstances, it would be fully staffed.  So the tool used to endow sequestration is itself no more of a barrier than a three-foot tall fence.  And this “fence” cannot fully impose the six-foot rule of social distancing because it will always serve as work space for at least one or two staffers, to whom the six-foot rule additionally applies.  The divider is potential disease vector itself (himself or herself).

But the entire configuration at Pediatric Associates begs a greater question, evidenced by a closer view of the “Well” entrance:

Just to the right of the door handle, a sign still advises to wear a mask.  On the entrance for “well” people.  Coming from an image dated April 2022, a good year since the City of Alexandria listed most of its mask-wearing requirements.

If the bifurcated entrances encourage sequestration, why is it still necessary for people to wear masks?  I understand that businesses mandate masking as a safeguard against liability at this point, and if any business exercises an abundance of caution, it should be a medical office.  But does Pediatric Associates ever get so crowded that it could spawn a “super-spreader” event?  It would be irresponsible for the schedulers to allow such a situation to occur, even if it’s highly unlikely that a medical office would voluntarily submit to contract tracing or any verifiable epidemiological audit.  Therefore, for those of us who (over)think these things, the mask requirement hints that sequestration provided by two entrances—and two separate waiting “rooms” connected through a single reception desk—isn’t really much of a safeguard.  And, most importantly, the masks and sequestration collectively evoke, along with most COVID policy these last two years, a sort of revival of miasma theory.  Broadly embraced until the mid-1800, miasma theory embraces an etiology that attributes the pathogenic qualities of disease to “bad air”—specifically, the particles that emit from decomposing matter propelled through the air.  Germ theory largely rendered miasma theory obsolete, since it recognized that actual pathogens (viruses, bacteria, or other non-organic irritants) cause disease, rather than air infused with poison.

Obsolete and antiquated though miasma may be in theory, the practices recommended to “stop the spread” of COVID-19 hint at the functional overlap with germ theory.  The 1893 invention of Köhler illumination helped confirm the presence of microorganisms previously undiscoverable in the era of miasma, yet somehow we’re supposed to presume any masks—even homemade cloth ones with holes between the threadwork that inhibit no germs whatsoever—are still better than no masks at all, when an expensive yet medically certified M95 mask is not readily available.  Or that double and triple masking are better than simply wearing one alone.  Furthermore, most studies in the earliest days of COVID confirmed that respiratory droplets propelled through coughing and sneezing—particularly when indoors and not exposed to direct sunlight—are the only true means of encouraging person-to-person COVID spread, something that sequestration by means of two entrances and a service desk will do little to prevent.  (After all, it’s extremely unlikely that the network of hallways and patient rooms at Pediatric Associates of Alexandria maintains this sequestration, meager though it may be.) These measures ultimately reveal that germ theory owes a great deal to miasma theory: epidemiologists may scoff at the latter, but their prescriptions owe a great deal to the thematic overlap between germs and bad air.  Meanwhile, the above-cited article recognizes that environmentalists have largely resurrected miasma theory to assert the deleterious effects of pollution on pulmonary health.  Simply put, car exhaust creates “bad air”.

In the future, can we expect to encounter sick and well entrances in a variety of medical offices?  Not likely—only if the liability costs increase to the point that the physicians at these clinics feel compelled to lease more space at the office next door, or to spend money to punch a hole in the exterior wall for a new entrance.  But it’s far easier and cheaper to just mandate masks until the end of time.  They’ll help us with all that miasma lurking outside of Pediatric Associates—and our kids too.