It hardly needs pointing out that Covid-19 has fundamentally changed the world around us. This is a pandemic visibly etched in unfamiliar markings on pavements and in stores. Public signs command us to observe the two-metre rule, to wash our hands, to dispose of paper handkerchiefs, and much else besides. Only a few months ago, who would have thought it conceivable that hospitals to ventilate thousands of intubated patients could be erected in the near blink of an eye. Many more spaces remain locked-down, their dimensions at odds with the new need for space, distance, separation, volume, freely circulating fresh air. Everywhere we look, the miniscule world of the microbial has been imprinted in the macro world of buildings, rooms, windows, walkways, passages, entrances and exits.
A return to the space/atmosphere of the body
There’s nothing necessarily new in this. The advent of antibiotics from the mid-twentieth century ushered in a previously unimaginable way of living, building and designing the world around us. Suddenly it became possible to treat the infected body pharmacologically and in almost complete isolation from the its context, the external space of the body. In the world before antibiotics, the bodies of the infected were dealt with environmentally and spatially rather than pharmacologically. The fresh air wards and pavilion hospital architectures of the pre-antibiotic period were designed entirely around a body firmly rooted in the nature of its space. This included the therapeutic exposure of the body to sunlight, the free circulation of fresh air, an attention to the distance separating one body from that of another.
However, the introduction of antibiotics from the mid-twentieth century made possible new concentrations of healthcare delivery within ever more efficiently compact clinical spaces. Hospital design now focussed on bringing bodies more closely together, reducing walking distances for clinical staff, improving thermal efficiency by limiting window openings. Hospitals also went vertical, stacking clinical spaces one upon another, within high-rise deep-density structures to be navigated by elevators and a rabbit warren of sunless corridors. The high vaulted ceilings of the Victorian age descended to more modern ceiling heights, further reducing both the vertical and horizontal dimensions of most buildings, both public and domestic.
The gathering crisis of antimicrobial resistance (AMR), and now the Covid-19 emergency, have radically called into question the built environment around us. What does this mean? Just as we’re starting to think about post-antibiotic architectures and designs, we are now inevitably speculating upon post-Covid-19 architectures and designs. And we’re seeing that happen. The eerily abandoned university college housing my office has been deemed far too small to be safely reoccupied, possibly even post-lockdown. The internal designs of buses, trams, trains are all being reconfigured to limit transmission. Hastily installed Perspex partitions are now beginning to appear everywhere.
The ascendency of the self-checkout and cashless economy has now swept aside any lingering attachment to whatever went before. ‘Touchless’ and ‘buttonless’ actions, from opening a door to moving around a public bathroom, are likely to become the rule rather than the exception. Is ‘contactless’ possibly now the dominant metaphor of the post-Covid-19/post-antibiotic age? Architecturally, two metres is likely to become a permanent building standard for internal corridors and walkways, just as it will be for external pavements and passages. The elevator, that classic of twentieth century architecture, may well have had its time. Urban and domestic infrastructure is set to be entirely redrawn. The Berlin suburb of Kreuzberg has doubled the width of its cycle ways to enable social distancing, eating into the vast volume of space gobbled up by cars. Other cities are following suit. The ‘zoomification’ of work, and the shift of occupational life from the office to home will inevitably highlight regressive changes to building regulations resulting in the shrinkage of domestic space since the 1970s.
All of this brings back an attention to the space of the body, its situatedness, its location in structures that are social, material and physical.
The ‘aerography’of breath, buildings and bugs
My own attention to the relationships between design, architecture and antimicrobial resistance is based on work undertaken with colleagues, patients and clinicians in cystic fibrosis clinics. Our research maps the real-world pathways, journeys and flows of bodies and bodies of air through clinical space, including the way atmospheric interactions are configured by the spatial dimensions of respiratory care. Until the 1990s, people with cystic fibrosis would routinely meet in open hospital wards, adjoining games rooms, waiting areas and on residential holidays. This emphasis on interactional intimacy changed fundamentally with the identification of resistant bacteria traced to cross-infection through interpersonal contact. Living with CF has increasingly come to depend upon a hygienic regime of spatial and atmospheric segregation, ritualised etiquettes of social distancing and a keen acuity to infection risks carried on the air.
Our work has also outlined a broader historical perspective making connections between aerographic reflections in medical humanities work on hospital architecture, but also a corresponding ‘turn to the air’ in the clinical sciences. We suggest that AMR has focussed interest in these fields on the atmospheric attributes of healthcare architectures across time (‘pre-to-post-antibiotic’). But airs and atmospheres pose particular challenges in infection control, often becoming a matter or deep doubt and guesswork. We reflect on the role of the imagination in visualising the invisible, including imagining patients located within bodily spheres, or ‘cloud bodies’. This is conceptually anchored in the French philosopher Luce Irigaray’s thoughts on the ‘forgetting’ of the air, and the German philosopher Peter Sloterdijk’s immunitary thinking on the spherology of the body. Our work has explored the material politics of air ventilation, air conditioning and window design, and the way competing air regimes conflict with each other, becoming flashpoints or ‘airquakes’ as Sloterdijk puts it at the interface of buildings, bodies and the biotic. We also explore how airborne infections become an aero-economic problem of atmospheric scarcity within high-rise, deep density modern healthcare architectures. It is, we suggest, worth speculating on responses to the AMR crisis – and now Covid-19 – by critically questioning contemporary healthcare atmospheres.
The coughing body: etiquettes, techniques, sonographies and spaces
With particular significance in the context of a pandemic, we have also focussed on what we call ‘the coughing body’ and how it is that the cough becomes a central organising social and embodied feature of life for people with respiratory illnesses. With some exceptions there is remarkably little research on coughing in literature related to the sociology and anthropology of the body. We take our initial cue from the anthropologist Norbert Elias whereby something as physiologically fundamental as coughing becomes a matter of proper etiquette and bodily technique, an unavoidable physiological imperative that must however be acquired, learnt and even taught. Coughing also touches on themes central to Mary Douglas’ anthropology of pollution, transgression and the ritualised restoration of bodily boundaries. Just as the antimicrobial resistance crisis has refocussed attention both common and rarer lung infections, Covid-19 ushers in a historical moment that attaches new and troubling meaning to coughs and coughing.
In the context of a respiratory pandemic, the sounds, sights and experience of coughs and coughing have become part of a public scenography with far-reaching social and biopolitical implications. Coughs define the geometries of the private and the public, the individual and the communal, the sacred and the profane. They give biopolitical meaning to waiting rooms, corridors, lobby areas and treatment rooms. That meaning extends to the invisible, the shape of air and what is ‘carried on the air’. Coughs perforate the distance separating one body from that of another. Such moments are reflex triggers for spatial repositioning, re-orientations within one’s immediate surroundings. One of our cystic fibrosis patients described his acute awareness of ‘… anybody coughing, sneezing, or anybody who looks unwell… I sort of take four steps across… or get a tissue and cover my mouth’. Respiratory vigilance is ‘as simple as looking both ways when you cross the road’, he said.
With respect to questions about infectious disease, contagion and pollution, there is something poignant in the way that sound constitutes a form of ‘touch’, direct contact, or physical interaction at a distance. The material force of the cough physically moves the air, travelling through space, entering and penetrating the body of the listener, oscillating and reverberating auditory tissues and nerve fibres. Coughing is ‘sono-material’, a ‘commotion’ in as much as it represents ‘noise’. But coughs are also ‘co-motions’ between bodies. They are directly physical, interpenetrative and intercorporeal in this sense. The cough collapses the distance between bodies; there is a slippage between auditory, acoustic and infective contagion at play in the sound of coughing. In the context of respiratory antimicrobial resistance, and now Covid-19, the cough has become a mode of ‘auditory work’, of ‘learning to listen’ to the body and the location of the body in space. Such sonographic labour is a belatedly under-examined dimension of scholarship on embodiment, let alone breath, breathing and respiratory life.
The thing that has become blindingly clear in the opening months of 2020, is that a new attention to the space/atmosphere of the body, its location in the built environment, is one of most powerful assets we have when it comes to tackling infectious disease. The antibiotics that once allowed the bodies of the infected to move freely and independently are now in crisis. At present, the few effective treatments we have for Covid-19 are space and air, ‘lock-down’, ‘distancing’, ‘self-isolation’, ‘shielding’. The fixing of the body in a particular atmosphere and geometry. Be it in the context of COVID-19, or the ‘slow-motion pandemic’ of AMR, the body has now been brought back into its situated space, its perilous relationships to others, its known and unknown contacts, newly nested in its socio-material relationships. It remains to be seen what the post-antibiotic and the post-Covid-19 worlds will have in common with each other.
Brown, N., Nettleton, S., Buse, C., Lewis, A. & Martin, D. (2020 in press) The coughing body: etiquettes, techniques, sonographies and spaces, BioSocieties.
Brown, N., Buse, C., Lewis, A., Martin, D., & Nettleton, S. (2020). Air care: an ‘aerography’of breath, buildings and bugs in the cystic fibrosis clinic. Sociology of Health & Illness.
Brown, N., Buse, C., Lewis, A., Martin, D., & Nettleton, S. (2019). Pathways, practices and architectures: Containing antimicrobial resistance in the cystic fibrosis clinic. Health.
Nik Brown is Professor in Science and Technology Studies (STS) at the University of York. His most recent monograph is Immunitary Life: A biopolitics of Immunity (Palgrave Macmillan). His most recent research focuses on healthcare architectural design and infections, especially in the context of chronic lung disease and cystic fibrosis. This research was supported by the UK Arts and Humanities Research Council (Pathways, Practices and Architectures: Containing Antimicrobial Resistance in the Cystic Fibrosis Clinic, 2018-2020, AH/R002037/1) and the Wellcome Trust/University of York Centre for Future Health (Architectures for a post-antibiotic age: the co-design of an exhibition, 2018-19).