Could COVID-19 Permanently Change Hand Hygiene?

An anthropologist tackles the slippery subject of hand sanitization in a world torn between concerns over contagion and antibiotic resistance.

Here in the Philippines, as in many parts of the world, there’s been an outbreak of hand sanitizers. Since late January, pump dispensers and bottles have appeared everywhere: airports, schools, dining tables, handbags. In SM, the country’s largest chain of shopping malls, large containers of hand sanitizers greet visitors as they pass through security. “This is a sanitized zone,” SM’s posters read. “Thank you for using the alcohol/disinfectant provided.”

When the enhanced community quarantine started here on March 17, sanitizer showed up at road checkpoints. And though the shops in the mall are closed, customers can still shop at mall supermarkets—after the staff sprays alcohol on their hands.
This is not surprising. The COVID-19 pandemic has spurred people around the world to panic-buy Purell and other hand sanitizers, soaps, and antibacterial wipes. What is surprising is that, until the pandemic hit Western countries, the trend was going in the opposite direction.

Over the past decade, there’s been a growing concern that the impulse to kill all germs could have serious consequences, such as the creation of resistant superbugs. This has certainly impacted people’s hand hygiene habits.

For the last few years, the U.S. Food and Drug Administration (FDA) has advised people to stop using antibacterial soap, which is no more effective at preventing illness than regular soap and may negatively impact health. After discovering that common ingredients in antibacterial soap—most notably triclosan and triclocarban—disrupt hormones in lab animals and induce antibiotic resistance, the FDA banned those chemicals in 2016 and replaced them with alternatives.

However, when soap and water are unavailable, hand sanitizers and wipes are considered an acceptable alternative because they rely on alcohol to vanquish certain viruses (including coronaviruses) and bacteria.

Still, before the current pandemic, some health experts urged people to cut back even on alcohol-based hand sanitizer. That’s partly because some bacteria are becoming more tolerant of alcohol. And it’s partly due to concerns that sanitizers might harm the microbiome—the trillions of microbes living on and in the human body that are essential for healthy immune function, digestion, and more.
In recent years, many researchers have expressed concerns that over-sanitized societies are contributing to autoimmune disorders, allergies, and inflammatory conditions. This “hygiene hypothesis” is controversial, but there’s no question that scientists and the public have been awakening to the fact that some microbes can be beneficial.

Yet in the midst of the COVID-19 pandemic, everyone is understandably consumed by the process of hand sanitizing, and many people are finding it nearly impossible to buy sanitizer online or in stores. People who just weeks ago purposely petted dogs to boost the diversity of their microbiomes now find themselves disinfecting their hand sanitizer bottles with antibacterial wipes.

To understand this sudden change, it is revealing to explore the complex history and anthropology of hand cleansing. What motivates people’s handwashing habits? How do beliefs about sanitizers and microbes figure in? How have previous epidemics led to shifts in these notions? And what might the post-COVID future hold for hand hygiene?
Even before 19th-century scientists discovered that germs cause disease, handwashing was important for hygienic and symbolic purposes in many societies and religious traditions. The Prophet Muhammad, for instance, called on Muslims to wash their hands in a variety of situations, including “before and after any meal,” “after going to the toilet,” “after touching a dog, shoes, or a cadaver,” and “after handling anything soiled.”

In other societies, hand hygiene practices primarily originated from secular discoveries. In 1846, Hungarian doctor Ignaz Semmelweis observed that mothers giving birth were more likely to die if they were treated by doctors who handled cadavers beforehand. So, Semmelweis mandated that hospital staff wash their hands with soap and chlorine. He later became known as the father of hand hygiene. A few years later, forward-thinking nurse Florence Nightingale implemented handwashing in British army hospitals.

Despite the efforts of these pioneers, the practice of widespread, regular handwashing was slow to take off in most of the world. In the U.S., the first national hand hygiene guidelines weren’t published until the 1980s, spurred by several foodborne outbreaks and hospital-associated infections. It was in that decade that a global hand cleansing movement was born.

The rise of hand sanitizers mirrors this move of hand hygiene from the hospital to the world at large. Some accounts claim that Lupe Hernandez, a nursing student in California, invented hand sanitizer in 1966 when she realized alcohol mixed with gel could help hospital staff clean their hands in a jiffy.

Others trace its beginnings to Gojo, a family-owned Ohio company that launched a hand cleanser for auto mechanics then tweaked the recipe and released it in 1988 as Purell. After a slow start, the product achieved the near ubiquity it enjoys today.
Incidentally, alcohol-based hand sanitizers once caused ambivalence among Muslims, owing to alcohol being haram (forbidden). But today, Muslim health care workers largely accept them, even though the question of whether hand sanitizers are halal (permissible) continues to spark debate.

Epidemics have repeatedly stimulated the popularity of hand sanitizers. In the Philippines, a clothing store called Bench introduced Alcogel shortly after the 1997 H1N1 outbreak. It attained “phenomenal success,” according to Bench’s CEO Ben Chan. A similar sanitization surge occurred in the U.S. during the H1N1 epidemic of 2009.
As The Guardian’s Laura Barton wrote in 2012, “Thanks to the heightened fear of contamination experienced during recent flu epidemics, there is now a value judgment attached to carrying and using an antibacterial gel.”

Infectious disease outbreaks have also influenced societies’ soap-and-water habits. A 2003 study of six international airports found that in Toronto—which was hit by a major outbreak of severe acute respiratory syndrome (SARS) that year—95 percent of male travelers and 97 percent of female travelers washed their hands in the public restrooms. By contrast, in New York’s John F. Kennedy Airport, only 63 percent of men and 78 percent of women washed their hands.

So, is fear of disease a great motivator for soaping up or squirting hand gel? Perhaps during a pandemic, the answer is yes. However, fear generally has only a temporary effect on ablutions, according to a review led by anthropologist Valerie Curtis. Furthermore, Curtis has warned, creating cleanliness campaigns that play on people’s anxiety is not good for mental health.

Instead, she recommends harnessing a different emotion.

In the early 2000s, Curtis was aiming to change the handwashing habits of people in Ghana, where only 4 percent of adults regularly used soap after going to the bathroom. Previous campaigns had failed, and the situation was urgent, since an estimated 84,000 children were dying of diarrhea each year.

So, Curtis created a campaign designed to generate disgust. At the time, bathrooms were considered cleaner alternatives to pit latrines, so they didn’t inspire an ick factor that might prompt Ghanaians to lather up. Curtis and her group developed ads that showed mothers and children exiting bathrooms with their hands covered in purple pigment, which they then transferred to everything they touched. Soap use subsequently rose by 13 percent following trips to the toilet and by 41 percent before eating.

Such a campaign could inspire future efforts in the wake of COVID-19. In a study released in December 2019, researchers at the Massachusetts Institute of Technology (MIT) and the University of Cyprus calculated that if travelers at airports raised the bar on their soap-use habits, the impact of a future pandemic could be reduced by 24 to 69 percent. Yet the same researchers estimated that, although 70 percent of air travelers wash their hands, most do not wash them adequately (frequently, with soap, for at least 20 seconds), so only 20 percent actually have clean hands.
Pandemics arguably tip the scale back to a Pasteurian paradigm.

Shifting views about microbes may complicate the issue of disgust. MIT anthropologist Heather Paxson has written that many people hold a Pasteurian worldview, in which they “blame colds on germs, demand antibiotics from doctors, and drink ultra-pasteurized milk and juice, while politicians on the campaign trail slather on hand sanitizer.”

But Paxson also points out that there is an emergent, alternative paradigm: a “post-Pasteurian” view. Post-Pasteurians “might be concerned about antibiotic resistance” and embrace microbiome diversifiers like probiotics, unpasteurized milk, kombucha, and unsanitized handshakes.

Since Paxson’s work was published in 2008, this post-Pasteurian paradigm has grown. Scientists have even considered ways they might promote more positive feelings for microorganisms and foster collaboration in human-microbe relationships.

Pandemics arguably tip the scale back to a Pasteurian paradigm. Currently, people are bombarded with images (and imaginings) of a potentially deadly virus for which there is, at least at the moment, neither vaccine nor cure. Thus, hand sanitizers and wipes emblazoned with the statement “kills 99.9 percent of germs” give people a sense of control over an unseen, and suddenly hostile, microbial world.
But people’s hand hygiene practices are also motivated by a visible and often friendlier force.

In 2016, researchers found that doctors and nurses at a California hospital washed or sanitized their hands 57 percent of the time when they knew that designated “hygiene patrol” nurses were watching them but only 22 percent of the time when volunteers who they didn’t recognize observed them.

Just like the wearing of face masks, social pressure can certainly motivate people to clean their hands. A recent review from Curtis and other researchers showed that people were more likely to lather up when there was more than one person present in a public restroom.

Prompted by the COVID-19 pandemic, some health experts are attempting to “responsibilize individuals” by framing handwashing as a selfless act that saves lives. Social media campaigns like #SafeHands and #HandwashingHeroes are also making appeals to social responsibility by showing celebrities and adorable children getting sudsy to prevent disease.

Similarly, face masks became an emblem of “public spiritedness” during the 1918 influenza pandemic. In some places, for instance, Japan, the practice of wearing masks continued and became part of the country’s hygiene culture.

In the aftermath of past pandemics, people have generally returned to their previous handwashing habits. But the COVID-19 crisis is different from other outbreaks. Never before have hand sanitizing and social distancing practices been enacted on such a global scale.

So, could COVID-19 cause permanent changes to handwashing habits around the planet? Could hand sanitizer become an enduring symbol of responsible world citizenship? Could the pro-microbe perspective swing back to a Pasteurian panic over germs?
Only time will tell. But it’s something to ponder while you scrub or sanitize your hands for at least 20 seconds.

By Gideon Lasco
He is a senior lecturer of anthropology at the University of the Philippines.
Published  8 April 2020

In a pandemic, hospital staffers need to get better at hand-washing

After visiting Ellis Island in 1906, President Theodore Roosevelt noted the lack of hand-washing by doctors and wrote the Public Health Service that he was “struck by the way doctors made the examinations with dirty hands,” turning the examinations themselves into “a fruitful source of carrying infection.”

Fast forward 114 years: Today’s hospitals aren’t doing much better at hand-washing. That’s a serious problem in ordinary times; during the Covid-19 national emergency it could become extraordinarily dangerous. One way the government can protect public safety is by immediately setting specific hand hygiene standards for doctors, nurses, and hospital staff.

There’s not even monitoring of a national compliance rate, although hand-washing remains “the most important intervention” to reduce the “staggering mortality” associated with hospital infections, according to an article in an infection control journal.

The most recent hand hygiene data — an 18-year-old study from the Centers for Disease Control and Prevention — is discouraging. It concluded that adherence “has remained low.”

How low is “low”? According to the CDC, health care providers in U.S. hospitals clean their hands less than half the time they should. In comparison, people using bathrooms in New York train stations washed their hands afterward 80% of the time.

The medical literature doesn’t show much systemic improvement in hand-washing since the CDC last looked at the issue or, for that matter, since the Public Health Service issued an educational video showing hospital staff how to wash their hands back in 1961!

Hospitals with hand hygiene compliance in the 50% to 60% range include the kind of large, urban medical centers designated by the CDC as “first tier” treatment centers during the 2014-16 Ebola outbreak. After reviewing hundreds of inspection reports, ProPublica recently reported that “infection control has been a recurring problem at some of the very hospitals that would likely be called upon to treat Covid-19 patients.”

Better hand-washing won’t solve all infection control issues, of course, but it would significantly improve safety. The first step to achieving it is valid measurement.

A new standard from the Leapfrog Group, a nonprofit focused on improving patient safety where one of us (L.B.) works, encourages hospitals to measure hand hygiene using electronic monitoring of clinician compliance. This kind of technology is commonplace in retail and other industries.
‘We didn’t follow through’: He wrote the Ebola ‘lessons learned’ report for Obama. Now he weighs in on coronavirus response

Hospitals traditionally measure hand hygiene by having someone spot violations and report them, a technique with questionable reliability. Monitoring hand hygiene in a way that yields accurate data is vital. The Leapfrog standard is evidence-based; the government should adopt it.

The next step, getting to universal compliance with hand hygiene best practices, is even more crucial.

Based on what hospitals have already shown they can achieve, the secretary of Health and Human Services should call on all hospitals to meet an 85% hand hygiene goal within 90 days. While President Trump’s well-known use of hand sanitizer even before the Covid-19 crisis should make this an easy step for the administration to take, its obvious importance should also draw support from both parties in Congress.

Meanwhile, the Centers for Medicare and Medicaid Services should start the process of issuing formal regulations that would include an aggressive time frame for 100% hand hygiene compliance by any health care facility receiving Medicare payments — which is virtually all of them.

It took 98 years from the time President Roosevelt pointed out the hand-washing problem at Ellis Island until U.S. hospitals were required to institute a hand hygiene program that followed the CDC’s recommendations. If a deadly pandemic doesn’t justify urgently demanding accountability for making patients safer by the simple act of clinicians washing their hands, it’s hard to imagine what will.

Leah Binder is CEO of the Leapfrog Group. Michael L. Millenson is a patient safety activist, researcher, consultant, and author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age” (University of Chicago Press).



By Leah Binder and Michael L. Millenson

Published March 25, 2020

How Do You Wash Your Hands To Fend Off Coronavirus If Water Is Scarce?

It’s something we’ve heard again and again from health authorities in the coronavirus pandemic. Wash your hands. Frequently. With soap and water. For at least 20 seconds. That’s an effective way to eliminate viral particles on your hands.

But for the 2.2 billion people in the world who lack safe drinking water — mostly in low- and middle-income countries — that advice will be difficult to heed. In these places, water is scarce for a number of reasons. It could be due to drought or climate change. Or local water supplies could be contaminated. Or the nearest source of water may be far away from home.

Aid groups and public health officials are doing all they can to help people in these communities overcome the obstacles and wash up. Washing your hands, they say, is a small action that can make a huge difference in the coronavirus pandemic.

“Hand-washing is one important tool to check and control spread,” says Amanda Glassman, executive vice president at the think tank Center for Global Development — along with other known interventions such as testing, isolating the sick and social distancing.

Water that is safe enough to drink is the best option for hand-washing. The ideal is to use clean, running water to wash away germs because it is less likely to contain harmful pathogens like e-coli, which can make you sick.

So how do you get water to those in need? Aid groups can truck in vast amounts of water, for example, but many say that’s expensive and unsustainable.

In less than ideal circumstances, other types of water can be used to wash hands. Non-potable water (for example, water that’s been used to clean dishes or do laundry) — along with soap — can be effective, according to a 2019 study published in the journal Environmental Science and Technology.

Small-scale solutions work, too – like setting up a network of public hand-washing stations – something done in West Africa during the Ebola outbreak of 2014. “When Ebola hit, one of the big concerns was the lack of running water and sanitation for hand-washing and proper waste disposal,” says Joia Mukherjee, chief medical officer of Partners In Health and associate professor of global health at Harvard Medical School. “It almost seemed like an unsolvable problem. And yet relatively rapidly, solutions were put together.”

The simplest kind of hand-washing station needs just two buckets. One bucket contained a mix of chlorine and water for the washing, with a spigot so people could tap into the supply, she explains. A second bucket, underneath the spigot, caught the wastewater.

These hand-washing stations were put in public buildings, schools and markets in Ebola-affected areas — and public health officials stressed why it was important to wash hands. Soon “people adopted this hand-washing technique everywhere,” says Mukherjee.

Mukherjee was heartened to see these stations again in February on trips to Liberia and Sierra Leone — set up by the countries’ health authorities to combat the spread of coronavirus. “I was very pleasantly surprised that they had already re-initiated this type of hand-washing at airports and outside of public buildings like the Ministry of Health. The lessons learned from Ebola were immediately being used.”

This kind of innovation is exactly what the developing world needs right now to ward off coronavirus, says Glassman, who is the author of Millions Saved: New Cases of Proven Success in Global Health. “We should deploy and test everything we’ve got,” she says, citing the hand-washing stations. “Affordability and fast availability is what matters now.”

The lower the technology, the better, says Glassman. If people can use objects and materials available in their own communities, like buckets, it makes the solution more likely to work.

One such device — which has been praised by global water researchers — is the SE200 Community Chlorine Maker. Developed by the global organization PATH, it can make chlorine from just water, salt and a car battery. Chlorine is commonly used to disinfect water because it kills many bacteria and viruses but isn’t always easy to obtain. The clean water can then be used to safely wash hands.

In preparation for the surge in coronavirus cases, 13 countries from sub-Saharan Africa as well as from Myanmar and Vietnam have put in requests to PATH for the devices. The group is finalizing logistics to get them up and running.

Then there’s the question of how to keep hand-washing stations safe from being a hot spot for disease transmission. Myriam Sidibe, a senior fellow at the Harvard Kennedy School, is working with the aid group WaterAid in Kenya to figure that out. They are trying to find ways to make 10,000 water stations across the country safe for people to congregate around.

The plan is introduce “social distancing nudges on the ground, similar to what we are seeing in supermarkets in some countries,” says Sidibe, who is based in Nairobi. “These can be red dots painted on concrete or if the surface is more uneven you can get stones or pieces of wood and sort of partially bury it in the dirt and then paint the visible bit red.”

As for soap, it’s not as much of a problem as water.

Soap is available to purchase almost everywhere in the world, says Sidibe. Most people, including those living in poverty in rural and urban areas, have some kind of basic soap, even if just for laundry, she says.

But in this time of crisis, soap supplies may run short — or people who lose their income because of the pandemic may find soap is not affordable.

In New Delhi, Sudhanshu S. Singh, CEO of the nonprofit Humanitarian Aid International, has been collecting donations of soap and hand sanitizer — increasingly in short supply as the city is in lockdown — for the 1,000 refugee families he serves in Delhi.

The families fled Pakistan from persecution and are living in camp settlements in a slum. Because they are stateless, they don’t have the same rights to water as Indians living in the slum, says Singh, and have even less access to water. “They’re living in absolute abysmal conditions. They’re vulnerable to different kinds of diseases and health issues. Eventually the virus is going to affect them.”

So far, he’s distributed a 15-day ration of hygiene materials and taught them proper hand-washing. To ensure the families have enough water to wash their hands, he and other groups petitioned the government to bring more water to the part of the slum where the refugees live. Last week, the authorities brought in a tanker of water to provide additional supply for drinking and hand-washing and will do so regularly.

But offering soap and water is no guarantee that people are going to wash their hands. In every country, from high income to low income, there are a lot of folks for whom a thorough scrub is not a regular habit.

“Just instructing people to wash their hands is not going to get them to do it,” says Sidibe, who previously worked at a project at Unilever focused on changing hand-washing behaviors in 55 countries. “People don’t practice hand-washing. It’s inconvenient and they have other priorities. To change behavior, you need to create an enabling environment. You need to establish a positive social norm. And you need to make it a desirable thing to do.”

In Nigeria, where there are only 111 reported coronavirus cases so far, aid groups like UNICEF have been emphasizing the importance of hand-washing in the low-income areas they serve. “We are trying to spread the message through celebrities, community and religious leaders, and reaching out to media and radio stations,” says Zaid Jurji, head of UNICEF’s water, sanitation and hygiene program, based in Abuja.

They’re collaborating with artists to sing about hand-washing, too.

On Sunday, UNICEF posted “We go win (Corona)” to their YouTube channel. It’s an original song from the popular Nigerian musician Cobhams Asuquo.

The lyrics go, “Corona no big pass us … as long as we remember to always do the right thing: wash your hands, love each other, we go win.”

The idea that a song could change behavior may seem naive, but it did work during the Ebola outbreak.

By Malaka Gharib
Published March 30, 2020

World Water Day: Hand hygiene essential to containing spread of COVID-19

Today is World Water Day. It is set aside to celebrate water and raise awareness of the 2.2 billion people living without access to safe water.

It is about taking action to tackle the global water crisis. A core focus of World Water Day is to support the achievement of Sustainable Development Goal 6: water and sanitation for all by 2030.

According to the UN, “The theme for 2020 is “Water and Climate Change” and explores how the two issues are inextricably linked.

“In light of the growing COVID-19 pandemic, the 2020 campaign also promoted messages around handwashing and hygiene and gave guidance on staying safe while supporting the campaign.

“The campaign also shows how our use of water will help reduce floods, droughts, scarcity and pollution, and will help fight climate change itself.

“By adapting to the water effects of climate change, we will protect health and save lives. And, by using water more efficiently, we will reduce greenhouse gases.

“Our key messages for this day are clear:

We cannot afford to wait. Climate policy makers must put water at the heart of action plans.
Water can help fight climate change. There are sustainable, affordable and scalable water and sanitation solutions.

“Everyone has a role to play. In our daily lives, there are surprisingly easy steps we can all take to address climate change.

“Hand hygiene is essential to containing the spread of COVID-19, as well as other infectious diseases. Wash hands with soap and water

Published 24 March 2020:

Slowing down transmission of COVID-1

One of the most important contributions we can make to slowing down transmission of COVID-19 and keeping ourselves and our communities safe is to wash our hands. Global COVID-19 Prevention.

This short animated video from Stanford Medicine illustrates how the novel coronavirus — the virus that causes the respiratory disease COVID-19 — is transmitted among people and how transmission can be prevented.

For more information, please visit

As the coronavirus spreads, the need for public handwashing facilities becomes vital

In pre-coronavirus days, about a third of all public restroom users washed their hands. That wasn’t good enough then and it really isn’t good enough now. During this pandemic, we all need to be washing our hands, often!

The problem we have now is a lack of public facilities to wash them, even though workers at establishments deemed essential—like hospitals, grocery stores, food delivery places—still have to work. Not to mention people who are out, while still practicing social distancing practices.

Access to public restrooms has diminished

In December I wrote an article on about the need for more restrooms and more accessibility for the diverse people within the region. I never imagined how relevant this topic would become during this pandemic.

WMATA closed the facilities in many Metro stations years ago. Elsewhere, there is a constant lack of public restrooms. Many businesses, during normal times, shut their restrooms off to non-customers. The opportunities we do have are often poorly maintained, under-staffed, and under-cleaned bathrooms long ignored by public agencies. Even interested parties often struggle to gain budgetary and staffing allowances to maintain public restrooms. So our hands often go dangerously unwashed.

People experiencing homelessness, immunocompromised people, trans and non-binary folks, people with disabilities, and older adults are especially impacted. Bathrooms are often inaccessible physically or due to socially-instituted barriers.

Trans and non-binary people often cannot use gendered restrooms, or cannot use them safely. Public restrooms are often an infection risk for immunocompromised people, even during normal times. Most bathrooms are inaccessible for people with disabilities and many older adults.

Businesses and institutions often demand payment before restroom use as a mechanism to exclude people experiencing homelessness. Not only does this mean that many people lack adequate opportunities to use the toilet, which leads to health issues, but also that members of these communities have fewer opportunities for hand hygiene.

Furthermore, some of these communities may be at greater risk from the coronavirus, due to the virus’ biology, common comorbidities, and limitations in accessing healthcare.

We already know that the majority of deaths from the virus are among older people and immunosuppressed people. Barriers to accessing healthcare are especially large for people with disabilities, trans and non-binary people, and especially people who are homeless.

Members of the last group often suffer from other health conditions that are potentially deadly when combined with coronavirus. Besides, barriers to healthcare are likely to surface in barriers to testing, or the ability to get a test at all, much less treatment. If people in these groups are unable to wash their hands, they are at greater risk to contract a virus that poses more of a threat to their well-being than for other people. This situation could be different.

What other countries are doing

In other countries, transit stations and interchanges offer frequent opportunities for handwashing. In Seoul and Dubai, most transit stations have restrooms with stocked and supplied sinks—as does much of the system in Istanbul. Pretty much every transit interchange in Japan and Australia has restrooms of some sort—including large bus stations. Many places also encourage hand washing and sanitizing throughout one’s day.

On Twitter, Michael Twitty recently observed a wide availability of hand sanitizer and opportunities to wash one’s hands in Senegal, with the encouragement and assistance of local leadership. In its most recent edition, The Economist noted that bus stops across the Indian state of Kerala were also providing hand washing basins.

In my own experiences in Jewish communities in the United States and Israel, the stand-alone sinks that are used for ritual hand washing are frequently used for hygienic hand washing too, even by people who are not observant of halakha.


What could we do here?

Reopening restrooms in Metro stations is a start. At the very least, these facilities—when maintained—offer a place for passengers to wash their hands, a habit that I hope continues after this pandemic. Also, making hand sanitizer regularly available throughout the WMATA system would be beneficial.

Adding restroom capacity at major interchanges would be helpful too. The restrooms installed in the 1970s probably do not meet the needs of a system that is currently far more heavily trafficked.

A program to install public restrooms and hand-washing stations across the region would be of great long-term benefit, especially for people who cannot afford to pay for services to which business restrooms are often tied.


Funding, staffing, and protocols would all need to be considered.

I am distinctly aware that installing these facilities costs a lot of money; the cost for adding a restroom facility is often about $250 to $300 per square foot. For a typical 56 square foot accessible bathroom, that comes out to between $14,000 and $16,800 – and that’s before labor costs, the cost of maintenance, and the cost of supplying toilet paper, water, and soap. The Portland Loo, a commonly-touted but ultimately problematic solution to restroom access, runs at about $90,000 per unit.

Installation costs are not the only expenditure: additional staff would be needed to make sure restrooms stay safe, in working order, and maintained. By and large, the reason public restrooms in many countries are usable is that resources are allocated to keep them that way. Workers would need to be properly paid, and provided the materials to keep bathrooms clean, and the time to do so regularly.

It is likely that additional protocols will need to come into place to keep restrooms clean and safe. One example might be automatic faucets or soap dispensers, which are already called for by the United States Access Board.

Yes, this will cost a lot of money and time, and maybe the political will won’t be there. But that is where our activism comes in. Funding choices are political and not choosing to allocate resources to essential things like hand hygiene is a conscious choice that can have drastic consequences. Besides, after the pandemic, we will all need to rejig our priorities to ensure health and safety in our public spaces.

As we move forward, let’s make sure that includes restrooms and the ability to wash our hands, as needed. Also, take other hand hygiene precautions: cough into your elbow, avoid shaking hands, and use your sleeves or elbow to touch surfaces when possible. After all, you don’t know when you’ll next be able to wash your hands.

Jonathan Paul Katz is a community planning student at the University of Maryland-College Park, and lives in Hyattsville. He is interested in the intersection of disability access and planning. In his spare time, he also writes a food blog, Flavors of Diaspora.

By Jonathan Paul Katz.
Published March 23, 2020

World Water Day 2020 highlights the essential role of handwashing

Good hand hygiene protects you and those around you. One of the most important contributions we can make to slowing down transmission of COVID-19 and keeping ourselves and our communities safe is to wash our hands. This is the main message of World Water Day 2020 on 22 March, and everyone has a role to play.

The provision of safe water, sanitation and adequate hygiene (WASH) is essential to protecting human health during all infectious disease outbreaks. Ensuring good and consistently applied WASH, environmental cleaning and waste management practices in communities, homes, schools, marketplaces and health-care facilities will further help to prevent human-to-human transmission of the COVID-19 virus. Strictly following good handwashing and personal hygiene practices is important for all, but especially in health-care settings, where it protects both patients and health-care workers.

Safe hygiene standards require a continuous and adequate supply of safe water, and sanitation systems that will continue to function even under stress or challenging conditions, such as under a changing climate. Within the WHO European Region, we have a strong multilateral mechanism: the Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. The Protocol’s primary objective is to promote the protection of human health and well-being within a framework of sustainable development, through improving water management, including the protection of water ecosystems, and through preventing, controlling and reducing water-related disease.

“Washing your hands is such a simple act, and yet such an essential step in halting infectious disease transmission and saving lives,” notes Oliver Schmoll, Programme Manager for Water and Climate at the WHO European Centre for Environment and Health in Bonn, Germany. “But in order to be able to maintain good hand hygiene, hospitals, schools and communities require a continuous supply of safe water and the availability of functional hand hygiene facilities and soap.”

To support water and sanitation practitioners and providers, as well as health-care professionals, WHO has recently published a technical brief, “Water, sanitation, hygiene and waste management for COVID-19”.

Published March 20, 2020

It’s still true: Good hand-washing is the best way to stay healthy

Everyone is concerned about staying healthy in the midst of the coronavirus pandemic.

But experts agree, one of the best things we all can do to prevent the transmission of any illness is to practice good hand hygiene.

“Wash your hands, with any soap, 20 seconds at least, or use an alcohol-based sanitizer — it will do the job,” said Dr. Frank Esper, of Cleveland Clinic Children’s.

Esper said germs can be transferred from person-to-person when we touch things like doorknobs, money or even other people.

“The grocery store, movie theater, for example, are all places where we all come together, and when you bring a bunch of people together, you’re bringing a bunch of germs together,” he said. “You can help prevent those infections by washing your hands.”

The good news, according to Esper, is we don’t need anything fancy to keep hands clean.

“A regular, good, generic soap will do just as fine as the expensive ones with labels that say ‘antibacterial’ and things like that,” he said.

Esper said parents can teach their kids good hand hygiene practices at any age — but usually once kids are of school age, they can get a better handle on how to wash up properly.

And for small children, hand sanitizer is a good choice.

“The youngest children — the 1- and 2-year-olds — are not very good hand-washers,” Esper said. “They generally have a hard time working with soap and water and doing the whole sequence. That’s where alcohol-based sanitizers help — you can just squirt it into their hands and rub, rub, rub — and it works so much better for the smaller children.”


By Elizabeth Misson, Cleveland Clinic News Service
Published March 6, 2020
Copyright 2020 by Cleveland Clinic News Service.

Clean hands save lives, so wash up, Berkeley expert says

Why aren’t we in the habit of washing our hands? Germs are invisible, and each of us has a hard time thinking of ourselves as a person with contaminated hands, says Berkeley Haas professor David Levine, an expert on overcoming barriers to improving health.

You don’t have to remind David Levine, UC Berkeley professor of business administration, to carry hand sanitizer and wash his hands thoroughly with soap.

But why do many of us — from children to adults — lack these habits, even in a pandemic? Much of Levine’s research focuses on ways to overcome barriers to improving health, especially in underprivileged nations. And as head of Hygiene Heroes, a program he’s led with UC Berkeley students on four continents since 2014, schoolchildren learn through the team’s special curriculum — it includes interactive stories, games and songs, and characters like Gerry the Germ — how to change health-related behaviors.

Berkeley News recently talked with Levine, a Berkeley alumnus who’s been on the faculty since 1987, about the importance of hand-washing, why people don’t always do it and what it will take for people and organizations to adopt healthier habits.

How did hand-washing become a focus in your work?

When I got tenure at Berkeley, I decided I should work on the most important problem I could help with. So, I chose the health of poor children in poor nations. Doctors taught me that hand-washing is the most important single behavior in preventing childhood illness, but the challenge of behavior change remained. And behavior change is something I study.

I’m currently working mostly in India. I have other behavior change projects on dental hygiene, safe water, safe cooking (to avoid smoky stoves that kill millions each year) and sexual and reproductive health. Any school can access my curriculum on hand hygiene and preventing respiratory infections; I’m glad to help run pilots or experiments.

Coronavirus has brought about death and also is a risk to businesses. I may start a small research project focused on when consumers prefer businesses with mandatory hand-washing and other signals of good hygiene. We will run some online surveys exploring what indicators of good hygiene are worth the hassle of longer lines or having to wash hands oneself. If good hygiene is profitable, it should spread more quickly.

What are the data on how hand-washing can prevent disease, and which diseases does it stop?
Hand-washing with soap prevents perhaps roughly a third of diarrheal diseases and a similar share of respiratory infections, such as colds and the flu. The proportion may be a bit lower for COVID-19, but we are not sure.

Both soap and hand sanitizer are highly effective. They key, in both cases, is to rub awhile. The standard advice is to rub for 20 seconds — about as long as it takes to hum “Happy Birthday” twice.

Elders often remind youngsters to wash their hands. Why doesn’t the habit stick? Is it a matter of not learning the right way, or not realizing why it’s important?

Leading doctors figured out it was important to wash hands with soap in the middle of the 1800s. But at the start of this century, most doctors did not wash their hands between patients. The result was that hospital-caused infections killed more people than auto accidents. Doctors’ hygiene has improved recently, but for 150 years, progress was quite slow. Germs are invisible, and each of us has a hard time thinking of ourselves as a person with contaminated hands spreading disgusting poop or snot around.

Has anything worked, to get people to change behavior and wash their hands — whether they’re surgeons or fast food workers or schoolkids in the bathroom? You’ve talked about the need to “harness shame.”

Interestingly, doctors did usually wash their hands — if they knew somebody was watching. We see the same pattern in public restrooms. Most people do not wash their hands with soap. But they do if they know someone is watching.

It’s important to establish a norm that it is disgusting not to wash hands with soap after leaving the toilet or before eating — and, more recently, not to wash hands with soap after a sneeze. (For guidance specifically on preventing the spread of COVID-19, see the CDC webpage)

To harness shame, managers must go beyond repeating messages to their employees about hand-washing to changing social norms. If they can convey the right messages, employees will feel disgust when they sneeze into the air or fail to wash hands with soap before eating. Effective change must build on messages about pathogens to include messages about poop and snot.

Washing your hands protects you — and the community. That is why social norms are important; we need society to use social pressure to protect itself.

What has your work promoting healthy routines in other countries shown?

Like many others, I find that providing easy access to soap or hand sanitizer is crucial. Also, like many others, I find that health messages — plus the availability of soap — is usually not enough.

Fortunately, even in resource-poor areas such as India, my team has found that adopting routines for hand-washing with soap work. When the lunch bell rings, students line up at the classroom door, and a lead student squirts a little soapy water on each student’s hands. The students scrub as they walk to sinks, rinse and then eat. Parents in our country may recognize this routine from their own children’s preschool days. Every school in America should establish similar routines.

What needs to happen to change health hygiene in the United States?

Managers in the United States must build new organizational routines related to hygiene. These will vary by the risks each business faces and must outlast the acute phase of this pandemic.

For example, hygiene is the most important near people who are sick. So, every doctor’s office should require people to wash their hands with soap or hand sanitizer as they enter.

It is important to establish routines for hygiene wherever people spend a lot of time together. So, every senior living facility should ask you to clean your hands as you enter. And places where people live together, like dorms and prisons, should establish appropriate routines for hand-washing before meals. For example, as you enter a dining area, someone can remind you to use hand sanitizer.

Good management has always involved a cycle of identifying problems and creating procedures to address them. Fighting COVID-19 requires using familiar management tools to address this novel threat.

First, businesses have to analyze where they can spread germs: an ATM keypad, a grocery cart, etc. Then, they have to create and implement procedures to keep workers and customers safe. Those new procedures require training, monitoring, incentives and often supplies. As a familiar example, the check sheets in some restaurants — “This bathroom was last cleaned by _________ at ___________ o’clock” — are part of an effective routine. Workplaces must extend that level of attention to hygiene to many other surfaces.

What opportunities does the current coronavirus pandemic present, to get people to adopt healthy or healthier hygiene habits? Are you optimistic about the chance for change?

Millions of people are paying more attention to hygiene today than they were a month ago. Some of the safer habits, like hand-washing a bit more often, will stick, but many people will become less careful when the pandemic dies down. I hope that organizations, from doctors’ offices to dormitories, can retain routines that keep people healthier.

Gretchen Kell
Published March 16, 2020

Wash your hands, Brother John!

Use of a six step hand hygiene technique as recommended by the World Health Organization is important to ensure thorough cleansing of hands, but learning and memorising the steps is a major barrier to its adoption. We hereby describe a musical mnemonic based on the popular nursery rhyme “Brother John” (also known as “Frère Jacques”) that can help learning and remembering of the proper technique.

Regular hand hygiene education at day care and school is recommended as an effective method to prevent gastrointestinal and respiratory infections, which are common in children.1 Hand cleansing may seem a relatively simple task, and the correct technique can improve the effectiveness of hand hygiene at eliminating microorganisms.2 Numerous studies have investigated the specific effect of school based hand hygiene interventions on infections and school absenteeism; however, few interventions have focused on how hand hygiene technique is taught to children.3

Using songs, in particular musical mnemonics based on popular nursery rhymes, may help children learn the process of hand hygiene techniques by making it more fun, thereby increasing attention and the development of memory and motor coordination.45 Learning through song lyrics, where the instructions are stated before completion of each step, has been shown to produce quicker acquisition of novel skills compared with prose self instruction.6

Children are exposed from an early age to musical mnemonics or cues that assist with learning (the ABC song for the alphabet, and the Head, Shoulders, Knees, and Toes song to identify body parts). However, few musical mnemonics exist to help teach hand hygiene to children. We reviewed a convenience sample of 15 videos online that targeted children to determine the following: presence of a musical mnemonic (with lyrics complementing each step of handwashing); song duration; and demonstration of decreased microbial burden as immediate visual feedback. We found no videos that showed the six step technique using a song mnemonic; the few that showed certain steps had songs that were longer than the recommended duration of handwashing (20-30 seconds) and were not easily reproducible by our school aged co-author.7

Fuelled by these findings, we decided to develop a musical mnemonic that targeted school aged children. We used the melody of a well known children’s song, Brother John (Frère Jacques), and incorporated the six recommended steps for hand hygiene. The lyrics were developed in collaboration with children of preschool and primary school age, ensuring that our intended audience could easily understand them, and leveraged the rhythmic and rhyme patterns of a popular song to improve memory retention.

The six steps to achieve effective hand hygiene, sung to the tune of Brother John (also known as Frère Jacques)
(fig 1, video on CLICK HERE TO SEE VIDEO

1. Are you sleeping // Scrub your palms
2. Are you sleeping // Between the fingers
3. Brother John, Brother John // Wash the back (one hand), wash the back (other hand)
4. Morning bells are ringing // Twirl the tips (one hand) around (other hand)
5. Morning bells are ringing // Scrub them upside down
6. Ding, ding, dong; ding, ding, dong // Thumb attack (one thumb)!Thumb attack (other thumb)! (sung with gusto)

Each line is repeated as is necessary to complete each step.

Fig 1

The six step technique for hand hygiene, as recommended by the World Health Organization, sung to the tune of Brother John (Frère Jacques) for song lyric self instruction in hand washing. Some steps involve doing one hand at a time. R=right L=left (image by N Thampi)

To investigate whether this song lyric self instruction method could be effective in reducing microbial burden, fluorescent marking was applied at the outset and hands were examined after washing with soap and water for residual fluorescence. Figure 2 shows reduction in the presence of fluorescent marking on the hands following handwashing while singing the musical mnemonic, indicative of potential effectiveness at decreasing microbial flora.


Fig 2

Fluorescent marking on hands, before and after handwashing using the song lyric self instruction. Fluorescent marks indicate presence of microbial flora. (A) Before handwashing, fluorescent marking under the black light is white and scattered throughout the palmar and dorsal aspects of both hands. (B) After handwashing there is a notable absence of fluorescent marking on palms, back of hands, and fingertips, with traces in the nail bed (image by N Thampi)

This song lyric self instruction has broad implications for school based public health campaigns. We showed that a musical mnemonic developed for preschool and school aged children can teach the World Health Organization hand hygiene technique effectively, potentially reducing infection transmission, with a duration of approximately 20 seconds. Given the longstanding clinical challenges of compliance with the six step technique, there is also potential for this musical mnemonic to be adopted in the healthcare setting; further testing would be required before definitive comparisons can be drawn. We plan to test the song in the classroom setting to determine its social acceptability, and its potential for peer-to-peer learning and long term memory retention. With its catchy tune and clear, lyrical instructions, our technique offers the opportunity to develop hand hygiene muscle memory, self-correction, and public health gains among children.

Acknowledgments The authors wish to acknowledge the children who provided early feedback on the musical mnemonic, particularly Ajay Villeneuve for demonstrating its ease of acquisition, use, and social acceptance among the preschool age group. We would like to thank Paddy Moore, Rhonda McIntosh, and Andre Coutu from CHEO Communications for producing and developing the video content, and the children who shared our enthusiasm for handwashing in song. A video demonstrating the six step technique using the musical mnemonic can be found at

Contributions NT and LNV conceived the musical mnemonic, YL contributed to the video, LNV performed the demonstration, NT and YL drafted and revised the manuscript. NT is guarantor.

Funding None received

Competing interest statement All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Guarantor N Thampi

Patient and public involvement The musical mnemonic was field tested among the co-author’s classmates and paediatric family members. All volunteered freely to participate.

Provenance and peer review: not commissioned; not externally peer reviewed.


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Published by: British Medical Journal –