Hospitals Should Let the Outside In

It’s remarkable what fresh air and sunlight can do for your health

In the only medical clinic on the largest island of the Galápagos, the warm Pacific ocean is clearly audible, lapping at the shore. When I was there, the clinic had no toilet paper or pain medication or ice, but it did have a light breeze wafting through its rooms. Anyone can walk down the clinic’s wide, sparse hallway and, by making no turns, opening no doors, soon be standing on the beach, the sun and the wind on their face.

The clinic on Isla Isabela—to which I arrived on a backboard in the open bed of a pickup truck, and where I might have died—is not open to the outdoors because of anyone’s intentional choice, however. It is open because there are few resources, and it is easier this way, and cheaper. In this case, doing things the easier and cheaper way probably saves lives.

Fresh air, it turns out, is good for us. As is sunlight. Our modern desire for control over all systems, driven by a reductionist vision of what science is and can offer, has, in this as in so many domains, made us less healthy, not more.

In the early 20th century, as post-industrial lifestyles were removing us ever further from nature, two medical treatments emerged that reflected a return to nature: open-air therapy, and heliotherapy. These are precisely as simple as they sound: expose patients to fresh air, and the sun. Patients with tuberculosis, and those with influenza, and soldiers who had been injured in WWI, were all successfully treated by placing them outside, in the sun. The sanatoria used for decades to treat tuberculosis patients were testament to the success of this approach.

As so often happens in modernity, however, shiny new technology soon arrived. In this case, the shiny new technology was antibiotics, which are one of the great successes of Western medicine. Instead of adding antibiotics to the toolkit available to doctors and at hospitals, though—instead of augmenting existing, successful treatment regimens with the new—the health professionals of the time largely replaced what had come before. Soon enough, hospital wards were fully enclosed, the patients secured inside, behind closed windows.

Research done since then has revealed what many people intuitively know: patients in hospital wards with no connection to nature fare less well, requiring more drugs, even than those who simply have a view to the outside. Imagine the power of actually being outside.

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Early in the SARS-CoV2 pandemic, one set of researchers found that, out of thousands of cases of COVID-19 that had been identified across several cities in China, only one case could be attributed to outdoor transmission. As the scientists wrote in the Discussion section of their paper, “The transmission of respiratory infections such as SARS-CoV2 from the infected to the susceptible is an indoor phenomenon”.

This finding is consistent with the failure of certain patterns to emerge during the pandemic: None of the protests from the Spring and Summer of 2020 seem to have been super-spreader events, for instance. Nor have we seen mass outbreaks among homeless people.

This research has been in the public domain since the Spring of 2020, available to all (and Bret Weinstein and I discussed it in April 2020, on an episode of the DarkHorse podcast we called “Life and Death Risks in an Era of Novelty"). Yet public policy has just barely begun to catch up. People in many parts of the country and world have had their ability to spend time outside strictly curtailed during the pandemic, no longer able to frequent parks or beaches. This kind of restriction is an outgrowth of misguided fear and the bad policy that comes of such fear. Such policy is not merely unnecessary, it is actually harmful.

So yes, it’s true what you’ve heard: sunlight is an excellent disinfectant. But it’s also true that cramped, windowless spaces in which the air feels stale and still are more likely to spread disease than are ones with an open door or window. In 2007, a study out of Peru compared older, naturally ventilated hospital rooms to fancy new rooms with entirely mechanical ventilation. In the old rooms, simply opening windows and doors increased airflow far more than was even possible in the high-tech counterparts. Open windows, lots of them, preferably on opposite walls to create a cross-breeze: it’s low tech, inexpensive, and superior. 

Furthermore, the bigger the space—the higher the ceilings, the larger the open windows—the less likely your neighbor is to get you sick. In that same study from Peru, researchers found that rooms built before 1950, which are large in volume, had a far lower estimated risk of transmission of tuberculosis even than the smaller rooms from the 1970s-1990s, which still had natural ventilation. 

The longer you spend time in a space with an infected person, the more likely you are to get sick. And if that space that you are sharing with an infected person is fully enclosed, with all windows and doors sealed, the more likely you are to get sick. And the smaller that space is, the more likely you are to get sick. By comparison, when you are outside, the “space” that you are in is effectively infinite. For many kinds of pathogens, if you are yourself sick, not only are you less likely to get someone else sick if you are outside, but you are also more likely to experience a better outcome yourself.

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Why, though? What precisely are the health benefits of being outside, of having airflow in your room—hospital or otherwise—or of having the sun on your skin? 

Science has generated a few answers to these questions. 

One is that many pathogens are density-dependent, meaning that they are more likely to successfully infect a potential host, the more of them there are near the host. Furthermore, if a disease is density-dependent, then the more pathogens a host has on board, the sicker that person is likely to get. Thus, bathing in your own viral or bacterial stew can make you more sick than if you exhaled or otherwise shed pathogens, and then they blew away on the wind. 

Another is that sunlight both induces the release of nitric oxide within the body, and produces vitamin D, both of which have multiple healthful effects. Among other known virtues, nitric oxide is part of the innate immune system, and enhances blood flow. Vitamin D, meanwhile, has been identified as having effects beneficial to the individual with regard to immunity, autoimmunity, cardiovascular disease, cancer, fertility, pregnancy, and dementia, among other things.

These explanations are true, so far as they go. But they reduce the value of being outside to its most basic, and in so doing risk missing larger, emergent truths. Our entire evolutionary history, until basically yesterday, was outside. We directly sensed the movements of sun and moon, navigating by their light and position. We tracked the tides, how they ebbed and flowed, and the length of days, which also wax and wane over time. We came to know the seasons and vagaries of the wind and the rain, and the timing of the harvest—of our grains, and of our favorite fruits on the vine or the tree. What precisely is the value of connection to nature? We do not know. Not knowing, though, does not render it unreal. Without a connection to nature, we ourselves wither on the vine.

I arrived at that clinic in the Galápagos immobilized, having been in a nearly fatal boat accident. It was bereft of many basic supplies, and would run out of more before my time there was done—no more gauze, or bandages, or tape. But the air was fresh, and anyone arriving there would be very unlikely to contract a respiratory disease—quite unlike the condition in many “modern” hospitals.

I walked out of that clinic broken, but alive. Many parts of me would be broken for a long time to come. But when I walked out of the clinic, I walked directly on to the beach, my bare feet in the sand, the sun on my skin, a warm wind blowing off the Pacific ocean. And I began to heal.