On Germs

Preface: We seem to have reached a point where we are no longer dealing with a brand new symptom, or treatment, every four days. And this gives me a chance to post some things I wrote earlier, which got subsumed in my efforts to keep folks informed about our goings-on. Here's the first, brought up to date a bit:

And the LORD spake unto Moses and to Aaron, saying, Speak unto the children of Israel, and say unto them, When any man hath a running issue out of his flesh, because of his issue he is unclean.

And this shall be his uncleanness in his issue: whether his flesh run with his issue, or his flesh be stopped from his issue, it is his uncleanness.

Every bed, whereon he lieth that hath the issue, is unclean: and every thing, whereon he sitteth, shall be unclean.

And whosoever toucheth his bed shall wash his clothes, and bathe himself in water, and be unclean until the even.

And he that sitteth on any thing whereon he sat that hath the issue shall wash his clothes, and bathe himself in water, and be unclean until the even.

And he that toucheth the flesh of him that hath the issue shall wash his clothes, and bathe himself in water, and be unclean until the even.

And if he that hath the issue spit upon him that is clean; then he shall wash his clothes, and bathe himself in water, and be unclean until the even.

Et cetera.

-Leviticus 15:1-8, KJV

So. While Susannah is (presumably) cured of leukemia at this point, she is now “neutropenic” or more properly, I think, “immuno-comprised.” That is to say, she has fluctuating levels of white blood cells, her immune system is basically naïve, and she is on large doses of immuno-suppresant drugs whose goal is to get her birth-body's cells and her donor-cells to Play Well With Others. So, as with AIDS patients, Susannah is vulnerable to bacteria, viruses, mold spores, and other pathogens that would have no impact whatsoever on most of us. In other words, she is vulnerable to germs, in the sense understood by germ theory before the Chamberland filter forced us to distinguish between tiny little organisms and way, way, tinier infectious agents like viruses and prions.

Although germs are invisible, they have been imagined since at least Avicenna, a millenium ago, and something rather like the germ theory has existed since time immemorial. As witness the passage above, which predates the great Persian genius philosopher-doctor-scientist by two thousand years. Every culture has some sort of vernacular germ theory, which fits into certain habits of mind that have to do with labeling and naming; with semiotics. I remember playing can't-touch-the-floor as a child, or trying to step only on the black tiles of a chessboard floor, or avoid stepping on sidewalk cracks. In those exercises, one's mind paints a mask of OK and not-OK surfaces over the world, and we do this very naturally. We utilize that kind of Boolean spatial thinking in many adult activities: putting a like-colored coat of paint on a wall, for instance, or brushing one's teeth, or even attempting to systematically search a room for some lost object, or search a checkbook register for an abberrant $11.15. It is an easy way for humans to think. And it is the basic axis of the continuum towards obsessive-compulsive disorder. It's just so fun to wash your hands one more time, because then they are virginal and pure. Until you touch something.

In the hospital, there was a particular version of this thinking that dates back (in a formal sense) to at least Ignaz Semmelweis, the Hungarian doctor who pissed everyone off and ruined his own life and saved many other lives by getting his colleagues to bleach their hands before doing obstetric exams. The hospital version of it went roughly like this:

• Everyone entering Susannah's room had to put on a mask—a process that involved touching our faces, so we then put disinfectant on our hands, and then put on gloves. If we wanted to, e.g., give her a hug, we also put on a gown.
• All objects coming into the room were supposed to be sterilized by wiping them with dimethyl benzyl ammonium chloride or some comparable biocide, all of them distant descendants of Semmelweis'es chlorinated lime. Items which could not be effectively sterilized in this manner (e.g., paper, or one's own clothing, or shoes) were miraculously exempt—the first of many signs that this protocol was not entirely rational.
• The floor of her room was considered to be permanently dirty, and so was anything that came into contact with it, although it was (cursorily) mopped with disinfectant every 24 hours.
• If Susannah's hands came into contact with her own body fluids (e.g., if she wiped her nose), she had to disinfect them. This drill became so routine that she usually followed it even when she had no idea where she was or what the hell was going on.
• If we (visitors) left the room, we had to discard our gloves and mask and start fresh when we returned.
• If Susannah left the room, she had to put on a mask and gloves.
• Et cetera.

These are not the highest level of sterile procedure; in fact, they are at least three orders of crazy below the protocols designed for certain pathogens. One feature of this is evident in the very architecture of certain hospital rooms, that have reversible air pressure. For patients like Susannah, the room is kept at positive pressure, to protect her from outside germs. For other patients—who might have tuberculosis or ebola or God knows what—the room is kept at negative pressure, as if to say: sorry, kid, we're gonna protect us from you.

As Susannah has gotten better, some of these restrictions have been waived, particularly in regard to me and her other regular caregivers (Jean, and Christopher, and Cheryl). I am necessarily going to be the harbinger of the first wave of germs she gets re-introduced to, so I no longer wear a mask or gloves, nor do they. Everyone else, though, is still supposed to be at mask-and-glove distance.

Meanwhile, my attention has been more focused on protocols for Susannah's environment. Nicole and I spent several days sterilizing the apartment, which entailed moving every single item out, repainting, and individually sterilizing all the objects we moved back in with bleach, alcohol, or ultraviolet light. (Quick: how many surfaces are there on a straight-backed chair with five slats? (Answer: ninety-one(!))) Keeping the place in something approximating a sterile condition is an ongoing challenge. The Yoshidas have sent us an amazing air purifier which, according to their research, is the best possible. It's a Diakin, you can't get them here, and all the controls are in Japanese, which Yuki has carefully translated for us. It's quite impressive. You know those motes of dust that dance in the sunbeams on lazy afternoons? We don't have those.

We've also had two wonderful consultations with Dr. Rachel _____, a nutritionist who works with bone marrow transplant patients. As the resident cook, I was initially concerned that the simple version of the neutropenia diet basically said “just eat frozen TV dinners for a year.” I explained to Rachel that I am a good cook, a food snob, and I understood about germs: I could handle the complex version of the diet. She immediately warmed up to this, and began to share, in conspiratorial tones, her own germ theories. “You know what is the most disgusting thing in the whole world? The insides of soft-serve ice cream machines. It's just this sugary goop, full of bacteria getting churned over and over, and no one ever cleans them....” She gave the sort of delighted shudder I associate with horror movie fans. “Also, salad bars. Oh my god, salad bars...” Rachel also believes that the people who give you free samples in grocery stores re-use the toothpicks. And of course: “you can never use too much bleach.”

And so I've learned another set of hygienic protocols, and have since been cooking up a storm. I've especially been working on Chinese cuisine, since it incorporates its own germ theory. (Even in medieval China, the street vendors sold boiling water. And almost none of their dishes involve any raw ingredients. Just try ordering a salad in a Chinese restaurant.)

* * * *

Now, all of these protocols are no doubt grounded in the best practices of generations of nursing experience, and we take them very seriously. But they occupy so much of one's time, so obsessively, that they become psychic entities in their right, with which one negotiates and argues. Not all the nursing staff in the hospital, for instance, agreed entirely on what needed to be sterilized when. So one can pick and choose between various versions of the sterile field. Moreover, we are all myopic to the various ways in which we are compromising the protocol ourselves, while being hypersensitive to the ways that other people are doing it. And there is endless room for mind games: if you drop a pencil on the floor, it is contaminated, but when you pick it up and clean it, are your gloves also contaminated? If so, does that mean your gloves are contaminated anew every time you touch something you need gloves to touch? There are answers to these questions, after a fashion—but the questions themselves occupy a lot of one's mental energy.

Ultimately, our minds prefer to work in absolutes, dividing the world into the Clean and the Unclean. But the reality of (empirical) germ theory, like so many other things, is that it is a probabilistic continuum. There are a few viroids and bacteria floating around even in the most spotless operating theater. Christopher actually caught a housefly inside Susannah's positive-pressure, bleach-scoured room, behind two sets of airlocks. Nothing down here on earth is completely clean, and that's OK, because the odds of any single pathogenic organism causing trouble are infinitesimally low. But it is hard...and scary...to think in terms of shades of gray. We like to think: I have passed a bleach sponge over this surface, it is Ultimately Clean. We do not like to think about chlorine concentration, exposure time, porosity, depth of penetration, bacterial resistance to biocides, differential life spans of bacteria on different substrates.

So to what extent are these protocols superstition, and to what extent praxis, or as the Positivists I have been ragging on lately like to say, “science” (Sorry, “Science”)? I don't know. Tonight I am back in South Hadley, slowly running an ultraviolet wand over our cutting boards. Maybe it accomplishes something. Maybe it's vital. But whatever it does or does not accomplish, I can't see the effect. And so it reminds me very much of blessing new houses in Bolivia: the priest reading the Our Father in Latin and sacrificing a llama; splashing its blood on the four walls; burying a foetal llama under the threshold. He used to go to some trouble to make sure he got the four directions right; the layout of the house itself might not be compass-aligned, you see. We all have our science. And if we discount the ravages of extreme poverty, all our science has probably not increased life expectancy by more than 15% since the days of Avicenna.

In 2010, in the United States, it is fairly clear that our own vernacular germ theory needs work. The appearance of MRSA and other highly resistant, iatrogenic pathogens seems to be largely a result of overzealous chemical attacks on germs which, left to their own devices, would have been relatively benign. At the same time, we are a culture that needs constant reminders to wash our hands after using the toliet. It is an odd juxtaposition. We as a people have access to very good science, but we must all operate at the level of superstition and habit. It is the interface that needs our attention.