Photo: Farooq Khan/Pexels.
From mid-March, there has been a steady stream of information on hand-washing as a defence against the novel coronavirus. Indeed, a host of disease-causing pathogens, bacteria and viruses can pass from hand-to-hand, hand-to-mouth and person-to-person. Hand-washing is not a panacea but along with better nutrition, vaccines and other interventions, this simple tool can help reduce the incidence of pneumonia and diarrhoeal infections that still cause one in four of all deaths among children younger than five.
We have been exhorted to wash our hands frequently, with soap and running water, scrubbing fingers and palms. However, clean hands are safe hands only as long as we don’t touch contaminated surfaces and then touch our faces. Pathogens easily get into the body through the mucous membranes of the face. Keeping our fingers away from the eyes, nose and lips is hardest: as soon as one becomes aware of this, one is overwhelmed by the need to rub one’s eyes or scratch one’s nose! Hands reach for the face all the time – an estimated 23 times an hour, according to one study.
What Hands Do All the Day is a telling film of daily life in a remote rural area of Bangladesh. It was made in the early 1980s by K.M.A. Aziz, a social scientist at the International Centre for Diarrhoeal Disease Research, Bangladesh (now known by its lowercase abbreviation icddr,b). The film reinforced what public health practitioners and epidemiologists were beginning to understand then: that clean hands are important to prevent the spread of infections.
Established in the early 1960s as the Pakistan-SEATO Cholera Research Laboratory (CRL) in Dhaka, the icddr,b became an autonomous, not-for-profit research institution in 1978. Today, it is reputed as a pioneering laboratory combining field-based research, training and treatment.
A notable early achievement was the development, testing and implementation of oral rehydration therapy (ORT) for diarrhoea. Cholera rapidly depletes body fluids, leading to death. Until the late 1960s, intravenous fluids were used to compensate for diarrhoea. But in rural areas far from modern hospitals, conventional intravenous treatment was impossible. So properly constituted oral rehydration solutions (ORS) made of glucose (sugar or jaggery) and salt that could easily be administered by a village health worker or family member proved to be a life-saver. Later, cereal-based ORS, with rice water and salt, was found to be even more effective.
Subsequently, icddr,b helped establish the efficacy of the oral cholera vaccine to replace the injected cholera vaccine, which had been used for 70 years but had never been rigorously tested. It showed that the injected vaccine was ineffective in preventing cholera or controlling epidemics, and was a waste of resources. It could even be dangerous because unsterilised syringes spread hepatitis.
In the 1960s, when the Dhaka centre began its work, the riverine Chittagong Division in what was then East Pakistan was continuously devastated by outbreaks of cholera. In 1966, CRL started a public health programme in the villages of Matlab in Cumilla (earlier Comilla) district. This is now probably the longest, continuously running public health programme in the world.
The Matlab health initiative was the learning and testing ground for ORS, which since has been adopted by over 100 countries, reducing the death rate from diarrhoea by more than half and saving some 50 million lives globally.
In India, the Johns Hopkins University Centre for Medical Research and Training, Calcutta (now Kolkata), was set up in the early 1960s, around the same time as CRL in Dhaka. The Calcutta centre was also involved in the ORT effort and the two centres were collaborators as well as rivals. In 1968, both the Calcutta and Dhaka groups published their results within months of each other. At Calcutta, a team led by the Indian paediatrician Dilip Mahalanabis demonstrated the effectiveness of oral rehydration in the cholera outbreak among millions of refugees who had fled from East Pakistan in 1971 during the Bangladesh war of Independence. Mahalanabis later worked with WHO, became director of clinical research at icddr,b, and founded-directed a not-for-profit organisation called the Society for Applied Studies, Kolkata.
J.N. Ruxin of the Welcome Institute for the History of Medicine, London, wrote in 1994, “Perhaps the greatest practical ORT success after Matlab was the Calcutta team’s work demonstrating that ORT could be implemented even under disastrous circumstances.”
In 1973, following an epidemic of dysentery in southeastern Bangladesh, icddr,b set up another field station in Teknaf in Cox’s Bazar district to monitor and treat diarrhoeal diseases. The narrow Teknaf peninsula, with its low forested hills, alluvial foothills, mangroves, mudflats, lagoons and salt pans, is bounded on the east by the river Naf and on the west by the Bay of Bengal. A continuous sandy coast stretches some 80 km from Cox’s Bazar, the district headquarters.
The peninsula was not as densely populated as it has since become, through internal migration and the influx of refugees. The river Naf marks the international border between Bangladesh and Myanmar. Today, Teknaf and Cox’s Bazar are in the news for the human rights and health issues of hundreds of thousands of Rohingya fleeing persecution in Rakhine state across the river, in northern Myanmar. (The icddr,b has also been involved in initiatives to prevent and control cholera and other infectious diseases in Rohingya refugee camps.)
The Teknaf health impact study began in two clusters of villages in 1980 and was methodically documented. Five years earlier, a census had been taken and thereafter 500,000 people in the villages of Teknaf were being surveyed regularly. The study measured health by the incidence of diarrhoeal disease and the growth rate of children under five. In the study’s first year, one village cluster got tube wells and hand pumps. In the second year, the same villages got pour-flush latrines. In the third, the villagers were given specific hygiene education and taught hand-washing. The control villages got none of the technology nor hygiene education but they could avail medical services at a diarrhoea clinic nearby.
Local religious and customary practices in the area emphasised bodily hygiene, including washing hands with a cleansing agent. When I visited Teknaf in late 1983, the very poor villagers told me that they would have preferred being given boats and nets to fish and improve their livelihoods; nevertheless, they welcomed the new taps and latrines and were using these facilities.
Everyone in the study villages, young and old, men and women, had also been made aware of modern hygiene rules about hand-washing, and they could repeat these when asked. There were other social changes. For example, women who had earlier been veiled and secluded began interacting freely with project staff.
But after four years, the project found that despite easier access to water, improved sanitation and hygiene information, the study villages were not healthier than the control villages. The incidence of diarrhoea in children was not markedly different. Why was the water and sanitation technology, and even hygiene education, not producing directly observable and measurable health benefits?
The villagers were aware of the need for hygiene but were they practising these rules? This is the question that led to What Hands Do All the Day. The film documented daily life in the village and clearly showed that customary hand-washing rituals and knowledge of hygiene do not translate easily into practice. Mothers cleaned infants who had defecated and then cleaned other children’s faces: germs were being passed from one set of hands to other hands, to faces and to food and drink.
Dr William B. Greenough III, who was then director of icddr,b, told me that the Teknaf project’s lesson was that the ‘software’ was at least as important as the ‘hardware’. (He is now an emeritus professor at the Johns Hopkins University, Baltimore, where – aged 88 – he continues to work on diarrhoea and oral rehydration among the elderly).
A later study in Mirzapur, Bangladesh, by B.A. Hoque and others reviewed the sustainability of hygiene education and women’s handwashing practices in villages and urban slums. The study noted: “Although hygiene practices in the intervention households were as poor in 1993 as they had been in 1987, they continued to remain significantly better than among the control population.” It also found that the ash or soil that poor women often used to scrub their hands yielded similar results as using soap.
During the ongoing coronavirus pandemic, icddr,b has been advocating an ingenious, low-cost solution to provide soapy water, tried and found effective in 2011 in urban Dhaka. It has also been encouraging those who do not have running water and find cakes of soap too costly to use 30 grams of ordinary washing detergent dissolved in 1.5 litres of water, in recycled plastic bottles hung at various places where people and children gather – providing soapy ‘running’ water.
If a film like What Hands Do All the Day were to be made in 2020 about what we educated, middle class people do with our hands during the day, it would be clear that this is not simply a problem among poor villagers or slum-dwellers women in a corner of South Asia. As we go about our daily lives, within the lockdown or without, we often forget to wash our hands, and we touch our faces all the time. This is also true of surgeons, physicians, nurses and other healthcare providers.
In India, the central and state governments, and international agencies such as UNICEF and NGOs, have made many efforts over several decades to improve water supply for the poor through bore-wells, the improved India Mark II hand pumps, piped water schemes and various appropriate low-cost technologies. The emphasis has always been on the technology – the hardware – and not much thought has been given to hygiene education and practice – the software.
The goal of the Total Sanitation Campaign (later called Nirmal Bharat Abhiyan) was to end open defecation by 2017. After the party at the Centre changed in 2014, the Centre launched a new campaign: the Swachh Bharat (Clean India) Mission, with a five-year deadline (October 2019) to achieve the goal of a nation free of open-defecation. According to the Department of Water and Sanitation website, over 100 million household toilets have been built since 2014.
There are reports of discrepancies in the data, but even assuming that almost all Indians have access to household toilets, we do not know whether and how these are being used and what impact this has had on the people’s health. The controversy over the number of latrines built itself highlights the fact that the hardware of the intervention has completely over-ridden the software of hygiene and health.
When hygiene does find a place, it is as a one-off, symbolic gesture. For example, on October 15, 2014 – ‘Global Handwashing Day’ – Madhya Pradesh won a Guinness World Record with 1,276,425 children in 51 districts participating in a massive hand-washing event. What impact has this event had on inculcating awareness and practice of hand-washing to reduce diseases and save lives? Has it affected children’s health in Madhya Pradesh in the six years since? (‘Global Handwashing Day’ was started in 2008 as an annual advocacy event by a group of international agencies, corporates in the health sector, the London School of Tropical Medicine and Hygiene, and USAID.)
Ignoring hand hygiene and what hands do all the day, every day, is perhaps surprisingly also a feature of medical practice, despite evidence that germs on the hands of doctors, nurses and health staff are responsible for patient deaths. In the 1820s, a French pharmacist-chemist Antoine Germain Labarraque established the use of lime and soda solutions1 as disinfectants. His work was translated in 1828 by James Scott, a surgeon, and published in London. Among other things, Labarraque recommended that doctors wash their hands with chlorinated lime to prevent ‘contagious infection’. This was before microbes had been discovered, when infections were believed to be caused by ‘putrid miasmas’, or poisonous air.
Two decades later, a Hungarian doctor named Ignaz Philipp Semmelweis realised that ‘cadaveric particles’ were being transferred from fresh cadavers in mortuaries to women in labour. There were two maternity clinics at the Vienna General Hospital where Semmelweis worked. One was attended by medical students and the other by student midwives. Deaths due to puerperal ‘childbed’ fever were more than three times as high in the medical students’ clinic as in the midwives’ clinic. Semmelweis realised that the students were performing cadaver autopsies and going immediately to attend to maternal deliveries, carrying the infections with them.
In 1847, Semmelweis introduced the disinfection of hands through chlorinated lime solutions in maternity wards and showed that this significantly reduced deaths. But because he could not explain how this worked, the medical-scientific establishment rejected it. It took a century for his place in history to be acknowledged. In the midst of the COVID-19 pandemic, in March 2020, a Google doodle recognised Semmelweis as the first person to discover the medical benefits of handwashing.
Also in the 1840s, in Boston, the US physician-poet Oliver Wendell Holmes Sr. was convinced, after studying case histories of women who had died of puerperal fever, that attending physicians were responsible for carrying the contagion. He published his findings in 1843 in the New England Quarterly Journal of Medicine and Surgery, but many obstetricians dismissed his work because he was not an obstetrician, according to Safiya Shaikh.
In his article, Holmes Sr. also cited the 18th century Scottish physician Alexander Gordon’s A Treatise on the Epidemic Puerperal Fever of Aberdeen (1795). In this work, Gordon expressed suspicion that he was himself a carrier of infection to his patients and that – depending on who the attending physician was – he could predict the women who would die of puerperal fever. Gordon’s treatise was deemed so controversial that he had to move out of Aberdeen.
Despite the discovery of microbes at the end of the 19th century, and the evidence that microscopic pathogens cause infections – the germ theory of disease – it would be several decades before surgeons, physicians and health care practitioners would accept that they could be responsible for infecting patients in their care. The most common healthcare-associated infections (HAIs) are those of the urinary tract, at surgical sites, pneumonia and infections of the blood caused by multi-drug resistant germs.
The data on HAIs is mind-boggling. In 2013, in a paper in The Lancet, researchers led by Benedetta Allegranzi of WHO estimated that worldwide “hundreds of millions of patients are affected each year, leading to substantial morbidity, mortality, and ﬁnancial losses for health systems.” On average, the paper says, HAIs “affects at least 7% of patients admitted to hospital in high-income countries and about 15% of those in low-income and middle-income countries.”
In Europe, HAIs affected over 4 million patients every year, causing 37,000 deaths. The paper cited data from the US Centres for Disease Control and Prevention that in 2002 there were at least 1.7 million cases of HAIs in the US, leading to 100,000 deaths. The annual costs were estimated at EUR 7 billion in Europe and$6.8 billion in the US.
In 2005, WHO had launched a global campaign for patient safety with the slogan ‘Clean Care is Safer Care’. Four years later, the WHO Guidelines on Hand Hygiene in Health Care (2009) said handwashing was the “first pillar of patient safety”. These strategies to ensure hand hygiene in medical care are recognised as the universal gold-standard. WHO also marks an annual ‘Hand Hygiene Day’ on May 5; in the current pandemic, this seems to have passed by quietly.
US surgeon and public health researcher Atul Gawande’s 2004 article ‘On Washing Hands’, also included as the first chapter of his book Better: A Surgeon’s Notes on Performance (2007), discusses how difficult it is for doctors to wash their hands between each patient. He writes,
“… we doctors and nurses wash our hands one-third to one-half as often as we are supposed to. Having shaken hands with a sniffling patient, pulled a sticky dressing off someone’s wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on — to see the next patient, to scribble a note in the chart, to grab some lunch.”
Almost no one adheres to time-consuming handwashing procedures. When alcohol gels, which are easier and quicker to use, are introduced, compliance improves. And yet, Gawande continues, if even 30% of doctors do not disinfect their hands, it still leaves enough “opportunity to keep transmitting infections”.
Microbiologist Purva Mathur, now a professor of laboratory sciences and in charge of infection control at the All India Institute of Medical Sciences (AIIMS), New Delhi, published a paper in 2011 in the Indian Journal of Medical Research, entitled: ‘Hand hygiene: Back to the basics of infection control’. The undisputed evidence, she says, is that adhering to hand hygiene practices reduces the cross-transmission of infections in hospitals. In clinical settings, alcohol-based sanitisers are recommended. This is especially important because microbes are becoming more and more able to resist drugs.
In 2016, Hindustan Times reported an internal study at AIIMS that found just the use of hand-sanitisers brought deaths due to infections among ICU trauma patients down from 54% in 2010 to 28% in 2015. Dr Mathur told the reporter, “Hand hygiene is the most important among all preventive measures in bringing down infection rates in ICU patients,” and that the hand hygiene compliance rate at AIIMS had “improved from 12% in 2010 to 64% in 2015”.
But if this is the position at the country’s premier medical institution, one can only imagine the extent of the hazard to patients in other hospitals and clinics. Perhaps the present pandemic, which has given wider currency to the software of health, will make medical professionals and people in their daily lives more conscious of hand hygiene.
Finally, the pandemic has also brought into focus the fact that basic science and its applications lie on a continuum. If we did not know about the lipid envelope of the coronavirus, we would be struggling like Semmelweis two centuries ago to explain why handwashing with soapy water works. There are many links in the chain. Years of basic research by scientists opened the path for ORT. The development of the oral cholera vaccine required us to understand cellular mechanisms and transport mechanisms across the intestinal wall. Discussing the human, societal and scientific history of cholera, Dr Greenough III says, “The legacy of cholera demonstrates how basic science – when brought to the bedside – can save lives, reduce costs and prevent disease.”
Almost four decades after K.M.A. Aziz’s film in distant Teknaf, What Hands Do All the Day, practising good hand hygiene, washing hands and keeping them away from faces continue to be critical to saving lives in different settings across the world.
Sumi Krishna is an independent researcher in Bengaluru.
Chlorides and hypochlorites of calcium and sodium↩