Washing hands with soap and water began as a religious ritual and cultural habit. Much later, it was connected to the reduction of illness and infection by Ignaz Semmelweis. Today, we’re well aware of the preventative capabilities of handwashing, but are we using this wellness tool as effectively as we could, and should?
Handwashing: A History
In 1846, Ignaz Semmelweis set out to solve a mystery. He’d discovered that new mothers were surviving at far higher rates in one of the hospital’s maternity wards than in another. The main cause of death was childbed fever (also called puerperal fever), which is a postpartum bacterial infection. The most obvious distinction between the two divisions was that, where the fever was most common, birthing was attended to by doctors and their students, whereas midwives were delivering babies in the other ward. Semmelweis posited that the students were, in some way, negatively influencing the outcome.
When confronted firsthand with the terrible toll that the disease was taking on young mothers and their families, Semmelweis was determined to find the cause. To do so, he personally autopsied all the mothers who had died of childbed fever the previous day before starting his ward rounds every morning.Nicholas Kadar, MD, JD, LLM, Roberto Romero, MD, DMedSci, and Zoltán Papp, MD, PhD, DSc, FACOG (Hon), FIAPM
“Ignaz Semmelweis: “The Savior of Mothers” On the 200th Anniversary of the Birth“
American Journal of Obstetrics & Gynecology
After many failed attempts to find a rational explanation, from investigating the impact of the position the soon to be mothers were put into during labor to questioning whether women were compromised by embarrassment at having male doctors, Semmelweis was close to giving up hope. But then the death of a colleague, unexpectedly, provided some fresh insight into the situation. That colleague, who’d pricked his finger while performing an autopsy, had contracted childbed fever. Given that only women who have recently delivered a child, or had a miscarriage, develop puerperal fever, Semmelweis determined it must have come from the corpse. This hypothesis also resolved the larger puzzle, since midwives, unlike doctors and their students, weren’t working with cadavers.
With this new knowledge came a brilliant idea… Washing hands, between working on the deceased and the living, could save lives!
What Semmelweis had discovered is something that still holds true today: Hand-washing is one of the most important tools in public health. It can keep kids from getting the flu, prevent the spread of disease and keep infections at bay.“The Doctor Who Championed Hand-Washing And Briefly Saved Lives“, NPR
Unfortunately, for a variety of reasons, the protocols Ignaz Semmelweis put in place did not catch on…
In the 1850s, Florence Nightingale liked to stay up to date with the latest medical research, then implement what she was reading about in the British military hospital, where she worked. Although she didn’t understand the science behind it, at that time, she was an advocate for proper hand hygiene. She used her knowledge of statistics, from private math tutoring in her childhood, to collect information that would show the value of the practices she had introduced.
Every nurse ought to be careful to wash her hands very frequently during the day. If her face, too, so much the better.Florence Nightingale, Notes on Nursing: What it is and What it is Not
Following the war, Nightingale fought for sanitation legislation, which significantly contributed to a subsequent 20 year increase in life expectancy.
In 1861, Louis Pasteur published his “germ theory”, establishing microorganisms as the cause of disease and infection. This was in sharp contrast to the competing conception that:
…diseases, particularly major killer diseases, arose in the first instance from a weakness or imbalance in the internal state and quality of the afflicted individual.“Louis Pasteur“, Science History Institute
Over time, Pasteur’s application of this breakthrough discovery led to his development of life-saving vaccines for fowl cholera and anthrax. He also reintroduced the idea of antiseptic cleaning prior to treatment, this time for both providers and patients. Pasteur also noted that this was far from a novel idea.
If these primitive forms of life could be destroyed by boiling, then why not by chemicals? Indeed, “antiseptic” substances had been used since time immemorial, even by the early Egyptians, and probably also before that.“Joseph Lister and the story of antiseptic surgery“
Hektoen International Journal, Hektoen Institute of Medicine
Jump forward to 1867, when Joseph Lister’s, “An Address on the Antiseptic System of Treatment in Surgery” was first published. In the article, he explained his innovative approach to surgery, which involved both using carbolic acid to clean surgical tools and dress wounds, and also handwashing.
Over the next ten years, the techniques he introduced were adopted by many surgeons. This was a necessary shift, given that:
Operations were so dangerous to their patients that there were calls to stop performing them entirely.Dennis Pitt, MD MEd and Jean-Michel Aubin, MD, “Joseph Lister: father of modern surgery“
The catalyst for his approach was the realization that patients who underwent surgery earlier in the day had better results and lower death rates than patients who were operated on later in the day. With our current knowledge of germs, it seems patently obvious that a lack of sterilization of hands, wounds, and instruments would further compromise each patient, through the day. But at the time, that was probably a shocking realization.
Lister was able to examine the issue because his father, Joseph Jackson Lister, had taught him how to use a microscope. In fact, his father’s tinkering with earlier models contributed to some of the key advancements that are found in modern microscopes.
Although carbolic acid is no longer the sterilization liquid of choice, we certainly wouldn’t be where we are today, medically, without Lister’s influence. In honor of his contributions, Dr. Joseph Lawrence named a surgical antiseptic he’d created after Lister. That rinse later became the first prescription product sold over the counter. Listerine continues to be used today, to eliminate germs that lead to plaque and bad breath.
Handwashing Goes Public!
For the general population, washing hands as a preventive practice lagged behind the medical field. In fact, the first national guidelines for hand hygiene weren’t released until the 1980s. Today, with all of our advances in medicine and technology, in many parts of the world people still aren’t able to wash their hands regularly. To make matters worse, in some of the places where people lack access to the tools for hand hygiene, they also lack sanitation systems.
No one’s going to refuse clean water. But the humble latrine, or flush toilet, reduces disease by twice as much as just putting in clean water. Think about it. That little boy who’s running back into his house, he may have a nice, clean fresh water supply, but he’s got dirty hands that he’s going to contaminate his water supply with.Rose George, “Let’s Talk Crap. Seriously.”, TED2013
But even in the most affluent, technologically advanced nations, people don’t always follow recommended guidelines. Even during cold and flu season, as experts are touting this convenient, inexpensive, and effective defense, few manage to meet what is minimally necessary to help prevent the spread of disease.
Of the 3,749 people observed in a study conducted by Michigan State University, the results of which were published in the Journal of Environmental Health:
- 15% of the men and 7% of the women did not wash their hands after using the restroom
- people were less likely to wash their hands when the sink looked dirty
- people were more likely to wash their hands when there were signs present reminding them to
Of those who washed their hands:
- 50% of the men and 22% of the women didn’t use any soap
- hand washing declined throughout the day (i.e. more people washed their hands after going to the bathroom in the morning than in the evening)
- only 5% washed long enough (minimally, 15 seconds) to kill infectious germs
Hand Hygiene, the Basics
People are typically advised to wet their hands, then lather with soap for, minimally, 15 seconds, before rinsing under clean, running water. EMed describes three distinct levels of “hand hygiene” (social, antiseptic, and surgical) and their main purposes.
In order to illustrate the difference between surgical and social hand scrubbing, here is an extremely abbreviated list of the multitude of steps that surgical staff follow prior to each procedure:
- Remove all jewelry
- Clean under the nails
- Scrub both sides of each finger
- Scrub between the fingers
- Lather the front and back of the hand
- Lather the arms past the elbow
- Rinse, beginning with the fingers, ending with the elbow
Again, this is just a small sampling of the full requirements.
Handwashing as a Preventative Practice
When to Wash
According to the Center for Disease Control (CDC) some of our prime hand washing opportunities include:
- food prep, including pet food
- caring for someone who feels ill
- treating cuts, wounds
- using the restroom
- changing diapers
- coughing or sneezing
- blowing your nose
- handling garbage
Additionally, during the pandemic, after:
- being out in public
- touching shared surfaces (counters, door handles, etc.)
- touching shared items (gas pumps, shopping carts, etc.)
- food prep, including pet food
- caring for someone who feels ill
- treating cuts, wounds
Additionally, during the pandemic, before touching your:
Helping Kids Develop Stellar Handwashing Techniques
I’ve seen a lot of tricks for getting children to take their time while they wash, here are a few.
- The Happy Birthday Song
- Row, Row, Row Your Boat
- Twinkle, Twinkle Little Star
- Old MacDonald Had a Farm
- The A, B, C song
A few people have even created (and posted) a song, specifically for (and about) handwashing. This one is my favorite!
Wash It Off:
- Have them draw a line on their hand with a marker, before they go to the restroom, they should scrub until they can no longer see that line
- Have them dip their hands in glitter and try (good luck) to wash it all off
Saving the World, One (Soap) Bubble at a Time!
Can handwashing save the world? I’m not sure, but it wouldn’t hurt to double down on our efforts. With such a long history of success, and clear evidence of impact, it would be silly not to take our time, and really soak up the suds.
So wash the front, back, and in-between. Get under those nails. Take your time, maybe make it meditative. Just remember to stop shy of ten minutes, more than that might be (bacterial) overkill…