The Human Cost of Failing to Name COVID āAirborneā
It was just going to be another routine day for a geriatric specialist. Dr. C woke up, got her three kids ready for school and kissed her wife on her way out the door. First stop was the local long-term care facility, located near her home in the northeastern United States. Dr. C, who asks that her name not be made public in this article, was in charge of checking on the elderly patients there one half-day per week.
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There was a bit of a twist to this morning in the late spring of 2020, however. Dr. C wasnāt going in wholly unprotected, as surgical masks were provided to protect her from the patients, and vice versa. These masks, sometimes known as medical or procedural masks, were common with both health-care workers and the public, their sky blue vivid on many faces. This, along with a plastic gown and a pair of gloves, were what she was given to protect herself from the COVID-19 virus.
She was led to believe that would be enough, because she was told the virus was transmitted via droplets created when sick patients coughed or sneezed, falling to the ground within six feet of the unwell.
She decided to leave the sickest patient, Benny, for last. His roommate had been diagnosed with COVID, but Benny had not, though he was feeling unwell. Despite public health assurances that COVID was not airborne transmitted, someone had put a HEPA filter in the room and opened the window. On Bennyās bedside table was his breakfast, still uneaten three hours after being left there. Dr. C sat down and held the juice to the aged manās lips, which he sucked back greedily.
āHeās too weak to eat or drink,ā Dr. C thought to herself, spending the next 10 minutes spoon-feeding him his morning meal and providing hydration. Although he wasnāt sneezing or coughing, and she was wearing all the right gear she had been told would protect her, she remembers thinking, āThis feels dangerous.ā
Four days later, she started to feel off.
Laws without effect
When COVID hit, laws were already in place that should have prevented infections in the workplace in Dr. Cās state as well as in Canada. Indeed, occupational health and safety, or OHS, regulations exist across the western world, built piecemeal over time as various illnesses and injuries were unveiled as related to the workplace. Each law, requiring employers to protect their employees from harm, exists because advocates such as labour leaders, unions, public health officials, politicians, lawyers and bereaved families fought for protections after harm had become obvious to all.
Initially, the primary focus was on factories, industrial sites and mines, with heavy-duty machinery and high-risk activities causing serious injuries. Later, they turned to unusual illnesses such as black lung in coal workers and lung cancer in uranium mine workers. Requirements requiring employees to wear personal protective equipment, or PPE, and other safety rules dramatically improved the health of workers in these industries.
The rules are comprehensive, stipulating every aspect of an employerās obligation to workers, such as how to safely store explosives, how many toilets must be on a work site and, yes, even how to protect workers from inhaled hazards, including asbestos, spray paint and respiratory viruses. And they have been effective, with U.S. records showing a 60 per cent drop in workplace fatalities, and a 40 per cent drop in injury and illness, in the 30 years after the Occupational Health and Safety Act was enacted, despite a doubling of the countryās population of workers.
In Canada, health-care worker safety was thrust into public consciousness with the 2003 SARS coronavirus epidemic. An illness transmitted almost uniquely through hospital patients, health-care workers and their families, the epidemic petered out through the use of airborne precautions in the hospitals, in particular universal N95 respirator masks, which fit tight to the face to ensure any air being inhaled or exhaled must pass through the mask filter.
In an effort to learn from this horrifying experience (438 cases and 44 deaths), the Ontario government created the Campbell Commission. It noted the strong resistance among many medical practitioners to acknowledge that SARS spread predominantly through airborne transmission. In its 1,200-page report, the commission highlighted the following:
The point is not who is right and who is wrong about airborne transmission. The point is not science, but safety. Scientific knowledge changes constantly.... When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today. We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. Until this precautionary principle is fully recognized, mandated and enforced in Ontarioās hospitals, workers will continue to be at risk.
It is painfully apparent that we didnāt learn the lesson in time for Dr. Cās visit to the nursing home. Although based in the United States, her experience is shared by health-care workers across North America. With rare exceptions, almost no jurisdiction used the lessons of the past to inform their response to the new virus. Indeed, six years later, we still havenāt learned it.
āHealth, safety and welfareā
Four days after visiting patients at the nursing home, Dr. C went out for her usual run, prepping for her next marathon. She felt increasingly unwell and tired during her normal route, so much so that mid-run she had to call her eldest son to come pick her up and take her home. Over the next 36 hours she continued to worsen, with sore throat, cough, diarrhea and extreme fatigue, but, unlike many, she never became severely unwell. She infected her wife, too.
A colleague attending the same long-term care facility, also wearing a medical mask, was infected and spent 11 days in the intensive care unit, retiring from medicine shortly after. Many nursing colleagues were also infected, including some who were ill and tired for much longer, months to years ā a symptom complex now called long COVID.
Canadians can take a lesson from Dr. Cās experience of being needlessly infected even though workplace safety laws, as written, should have protected her. Had she instead practised in Alberta, for example, here are some passages from the provinceās occupational health and safety legislation that Dr. C might have assumed were crafted to keep her safe:
Obligations of employers 3(1). Every employer shall ensure, as far as it is reasonably practicable for the employer to do so, (a) the health, safety and welfare of (i) workers engaged in the work of that employer... and (iii) other persons at or in the vicinity of the work site whose health and safety may be materially affected by identifiable and controllable hazards originating from the work site.
And this:
228(1). If the hazard assessment indicates the need for personal protective equipment, an employer must ensure that (a) workers wear personal protective equipment that is correct for the hazard and protects workers, (b) workers properly use and wear the personal protective equipment, (c) the personal protective equipment is in a condition to perform the function for which it is designed, and (d) workers are trained in the correct use, care, limitations and assigned maintenance of the personal protective equipment.
247. An employer must ensure that respiratory protective equipment used at a work site is selected in accordance with CSA Standard Z94.4-02, Selection, Use, and Care of Respirators.
And this:
244(2). The employer must consider (a) the nature and exposure circumstances of any contaminants or biohazardous material, (b) the concentration or likely concentration of any airborne contaminants, (c) the duration or likely duration of the workerās exposure, and (d) the toxicity of the contaminants.
In reading the legislation, it is clear that the employer has a responsibility to protect health-care workers like Dr. C from bioaerosol hazards. There is no mention anywhere, in any OHS legislation, including the quoted Alberta version, that the medical masks issued to Dr. C constitute protection from an airborne-transmitted hazard like the SARS-CoV-2 virus.
Itās important to recognize that medical masks were never designed as respiratory PPE and, until recently, were never purported to be such. They were designed as splash guards: to keep the wearerās respiratory droplets from flying into a patientās surgical field, and to keep blood and other body fluids from spraying into the wearerās nose and mouth (that is why they are fluid resistant).
Respirator masks, which are explicitly referred to in OHS legislation as the appropriate PPE for airborne hazards, are designed specifically to prevent inhalation of threats like asbestos or COVID-19. They have a much better filter than medical masks, but more importantly, they fit tight to the face, so that all air inhaled into the lungs must first pass through the filter.
Loose-fitting medical masks allow air to enter through the sides, making them inherently much less safe. Ironically, it is why they are sometimes preferred by wearers: the loose fit means less breathing resistance, and less pressure on the face. But that also makes them inadequate for the purpose.
Why so shy about saying āairborneā?
Dr. C continued to work remotely a few hours a day through her illness. Her sore throat and cough quickly cleared, but the malaise and the fatigue persisted beyond the expected two weeks of recovery. She began working one day a week, but that would wipe her out for the next six days... until she tried one more time to push through.
One month into this cycle, she started reading in earnest about possibilities. It reminded her a lot of her teenage selfās recovery from mononucleosis, which took about 18 months. Going through medical school she had had a single lecture on myalgic encephalomyelitis, or ME, formerly known as chronic fatigue syndrome, and had never even heard of postural orthostatic tachycardia syndrome, or POTS. But going through her symptoms, these two syndromes correlated with her symptoms pretty well. And the new entity of long COVID, which the medical world was just beginning to comprehend.
How is it possible for hospitals, nursing homes and other health-care employers to allow respiratory PPE that doesnāt fit the legal standard previously set for protecting workers against an airborne hazard?
Simple. They just fail to explicitly state the virus is airborne.
Despite the strong evidence of the 2003 SARS virus being airborne, and the 2007 Campbell Commissionās clear recommendation to treat future pandemics as airborne, the World Health Organization explicitly asserted over and over again in the early pandemic that COVID-19 was not airborne spread but instead contracted through contact with droplets flying from sneezes and coughs, or on surfaces where the droplets have landed. (Remember wiping down your groceries in March 2020? For the public, that lasted about two months, when we realized it was not useful to prevent infection.)
To say a virus is transmitted by contact or droplet implies there isnāt a threat posed by simply sharing air with a sick person. Which in turn would mean medical masks are OK and necessary only if someone is coughing or sneezing those droplets into your vicinity.
Except, on top of the evidence generated by the 2003 SARS epidemic, there was soon a substantial increase in the evidence that SARS-CoV-2 was similarly spread by airborne means.
There was also a clear lack of evidence of spread by contact or droplets. The U.S. Centers for Disease Control and Prevention famously came out with a statement that the risk of contracting COVID-19 was extremely low, at one in 10,000. But in April 2021 the same CDC and the WHO were forced to acknowledge the significant role airborne transmission played. It took until November 2021 for the Public Health Agency of Canada, or PHAC, to follow suit.
So how is it still possible that the Canadian OHS laws donāt apply, requiring the appropriate PPE for airborne spread?
PHAC, to this day, has never used the word āairborne.ā Itās merely implied, muting what should have sparked sweeping changes.
The āannouncementā by PHAC that COVID was airborne was issued online (and notably, not in a press conference) in November 2021. The statement described how āthe virus can linger in fine aerosols and remain suspended in the air we breathe, much as expelled smoke lingers in poorly ventilated spaces,ā which describes aerosols causing airborne transmission.
Today, the PHAC website on COVID transmission mentions breathing in particles that can linger in the air, a euphemism for airborne transmission. The section on preventing infection includes improving ventilation in indoor spaces, again only useful to prevent airborne transmission (by decreasing the concentration of aerosols).
But in all cases the word āairborneā is strangely missing.
For years, the advice to the public was to wear the ābest made, best fitting mask,ā terminology that only describes a respirator-style N95 mask, essential for mitigating airborne transmission. Thankfully, more recently PHAC is now explicitly recommending respirator masks (along with medical masks) for the public. Ironically, and tragically, the general public is advised to take better precautions than health-care workers, many of whom are still caring for COVID patients.
Itās difficult to know why the word āairborneā is avoided so consistently, but the impact is clear: without that word, occupational health and safety requirements can be evaded.
Even today, if you were to walk into a room in a hospital with a COVID-19 patient, the warning on the door would say that PPE requirements are to prevent contact/droplet transmission. No mention of airborne transmission. No need to use an N95 respirator mask.
This results in the very strange situation of walking through hospital wards under renovation and seeing construction workers in full PPE (including an N95 respirator to protect them from construction-related aerosols) while health-care workers wear either inadequate medical masks or no masks at all.
Long COVIDās long shadow
Dr. C hasnāt worked as a physician since stopping three months after the onset of her illness. She is upright for only one to two hours per day. Her symptoms havenāt really improved over time, but sheās gotten better at managing them. Something as simple as attending an online medical conference, sweeping the floor or reading a book can cause her to ācrash,ā a long-COVID term that means a setback causing severe fatigue, worsening symptoms such as headache, gastrointestinal distress, a sore throat and increased disability for days to weeks. After Dr. C was forced to stop working, it took two years to find a physician to replace her.
The infection she passed on to her wife also lingers as long COVID, though her symptoms are less severe. Imagine the challenges of running a household with kids with two parents needing caretaking.
A work-related illness investigation was conducted to understand how Dr. C contracted COVID. During an interview her boss told her it was likely she had made a mistake putting on or removing her PPE, resulting in her infection. Dr. C disagrees.
At no point has the facility acknowledged that inadequate PPE, insufficient to prevent the airborne transmission of COVID, might have been a factor in her occupational illness.
For Alberta health workers, one more highly relevant passage from the provinceās occupational health and safety legislation is this:
33(6). If an injury, illness or incident or worker exposure occurs at a work site, the employer shall (a) carry out an investigation into the circumstances surrounding the injury, illness, incident or worker exposure, (b) prepare a report outlining the circumstances of the injury, illness, incident or worker exposure and the corrective action, if any, undertaken to prevent a recurrence of the injury, illness, incident or worker exposure.
And still health-care workers are being hurt on the job. Exactly how many is difficult to say, because data is extremely hard to come by. Alberta stopped reporting health-care worker deaths in March 2022. By then 12 had died from COVID. A report from the Canadian Institute for Health Information stated that by March 2022, 150,000 health-care workers had been infected, and there had been āat leastā 46 deaths countrywide.
Disability from long COVID is also rampant among health-care workers, but again, data is sparse in Canada. A recent U.K. analysis found that as many as 40 per cent of health-care workers in that country have had long COVID. Because the United Kingdomās infection prevention protocols have been identical to those in Canada, it is likely health-care workers in this country have fared similarly. Likely this has contributed to the significant, persistent post-COVID shortage of health-care workers.
A call to action
Our politicians and policymakers must address the looming question. Is it possible that health-care workers were inadequately protected during the pandemic ā and continue to be unnecessarily exposed to serious risk? That the PPE used was inappropriate for the hazard?
Embedded within all OHS legislation is a system for identifying improvements to an organizationās OHS plan. Each major injury, illness or incident is to have a full investigation, and ācorrective actions undertaken to prevent a recurrence.ā
In the middle of the pandemic, in Alberta in 2021, there were 25 workplace fatality investigations by the government. None of them were for the health-care workers who died from workplace infections. It is unclear why dying from an occupational injury is deemed worthy of an investigation to prevent future occurrences, while dying from an occupational disease is not. Especially with the numbers involved.
Dr. C knows there is no going back to a time before her workplace-acquired long-COVID disability. She wishes she could have been fully informed of the risks, and methods of preventing infection. She dreams of a future where all health-care workers are fully informed about airborne transmission and the risks of long COVID, and are provided with the right PPE. She hopes not a single other colleague has to suffer the preventable challenges she faces every day ā yet even now she continues to meet other health-care workers who have recently developed disabling long COVID.
People are tired of the COVID pandemic. There is a desire to move on. But even today, as we write this, there continue to be outbreaks in hospitals and long-term care facilities in Alberta and elsewhere in North America.
In Canada, government data shows that in the week ending March 8, 2026, 34 per cent of COVID patients in hospital acquired the virus while in hospital.
How many either communicated the COVID virus to a poorly protected health-care worker or received the virus from a health-care worker who was left without adequate defences, such as properly filtered air or an N95 mask, to ward off the virus? We know, because studies have shown that respirator masks are better than other medical masks at preventing an infected person from infecting someone else.
Here we are, six years after every province and territory in Canada declared states of emergency because of COVID, and yet we have not learned basic lessons from the pandemic. We must act to prevent future Dr. Cs, and the thousands like her, from getting seriously and needlessly sick on the job.
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