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| ‘At the start of a pandemic, this is pretty much all you’ve got.’ | Photo by Camille Van Vooren / EyeEm / Getty Images. |
By Amy Fleming, The Guardian
It felt strange when Boris
Johnson emerged from the first Covid-19 Cobra meeting on 2 March and
told us to wash our hands while singing Happy Birthday. The preppers
among us had panic-shopped while awaiting his pronouncements, and others
fretted about vulnerable loved ones, travel plans, the nightmare of
simultaneous homeworking and home-schooling, and not being able to work
at all. And all our leader had was this?
As one of the few things we can do to
significantly stop the spread of coronavirus while out in the infectious
world, the new rules for this everyday habit have become the meme du
jour. The Killers’ frontman, Brandon Flowers, tweeted a video of himself
lathering up while crooning his hit Mr Brightside to 4 million
followers. Judi Dench and Gyles Brandreth have posted themselves online
reciting The Owl and the Pussycat with sudsy hands. A website for
generating handwashing infographics to the song lyrics of your choice has gone viral.
To Nancy Tomes, a distinguished professor of
history at Stony Brook University, New York, seeing this basic advice
headlining the public health agenda has felt even more strange. “Being a
historian of this kind of pandemic event and then experiencing this
one,” she says, “is kind of like being a passenger on the Titanic and
watching it all unfold.” It also feels, she says, like going back to the
early 20th century, when infectious diseases such as tuberculosis and
smallpox were the No 1 cause of death, and the new science of germs had
led to the first mass obsession with hand hygiene.
Religious handwashing rituals have been around
for thousands of years in Islamic, Jewish and other cultures, but the
notion of disease spreading by hand has been part of the medical belief
system for only about 130 years. However, the first recorded discovery
of handwashing’s life-saving power came 50 years earlier, in 1848, as a
huge, unwelcome shock.
“If there had to be a father of handwashing it
would be Ignaz Semmelweis,” says Miryam Wahrman, a professor of biology
at William Paterson University in New Jersey and author of The Hand
Book: Surviving in a Germ-Filled World. While working at Vienna General
hospital, the Hungarian doctor was at the forefront of a more scientific
approach to medicine. Faced with a doctor-led maternity ward in which
maternal deaths from the dreaded childbed fever were significantly
higher than in the midwife-run clinic there, he racked his brain for
clues as to why.
Germs were yet to be discovered, and it was
still believed in the 1840s that disease was spread by miasma – bad
smells in the air – emanating from rotting corpses, sewage or
vegetation. Victorians kept their windows firmly shut against such
malevolent forces. So it didn’t seem a problem that trainee doctors at
Vienna General would hang out in the morgue dissecting corpses to figure
out what had rendered them dead and then pop up to the maternity ward
to deliver a baby without washing their hands.
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| The medical pioneer Ignaz Semmelweis washing his hands in chlorinated lime water before operating. | Photograph: Bettmann/Bettmann Archive |
One of them then accidentally got cut by a
scalpel during a dissection and died, seemingly of the same childbed
fever the mothers had been getting. Semmelweis hypothesised that
cadaverous particles from the morgue were to blame, and that such
particles on the hands of doctors were making their way into women’s
bodies during childbirth.
To test his theory, he ordered doctors to wash
their hands and instruments in a chlorine solution, a substance he hoped
would dispatch the deadly smell of cadaverous particles. Before the
experiment, says Wahrman, “the mortality rate for new mothers was as
high as 18 percent. After Semmelweis implemented hand hygiene between
the morgue and the delivery room, the rate of mortality for new mothers
dropped to about 1 percent.”
Despite his success, his idea faced great
resistance, and met a tragic end. He lost his job, and is thought to
have had a breakdown. He died in a psychiatric institution, “a very
despondent person at the untimely age of 47”, says Wahrman.
Part of the problem, says Tomes, was that
people, “didn’t have that conception of themselves as sort of walking
petri dishes”. And doctors were offended by the suggestion that they
could be causing infections. “The majority of doctors in Vienna at this
time were from middle- or upper-class families, and they thought of
themselves as very clean people compared with the working-class poor. He
was insulting them when he said their hands could be dirty.”
Over the next 40 years, an understanding of
germs developed, and attitudes to hygiene gradually shifted. In 1857,
while Semmelweis’s mental health declined, Louis Pasteur, of
pasteurisation fame, raised awareness of pathogens, and how to kill them
with heat. In 1876, the German scientist Robert Koch discovered the
anthrax bacillus, kicking off the new research field of medical
bacteriology. Cholera, tuberculosis, diphtheria and typhoid bacilli were
subsequently identified.
Surgeons started handwashing in earnest. Tomes
says: “If you’re cutting open someone’s skin – that protective layer –
you need to take extraordinary precautions.” The British surgeon Joseph
Lister pioneered antiseptic surgery, which included handwashing, “and by
the 1890s and into the early 1900s,” adds Tomes, “handwashing moved
from being something doctors did to something everybody had been told to
do”.
Florence Nightingale helped. Despite still
labouring under miasma theory, she intuitively improved hygiene in
military hospitals during the Crimean war in the 1850s and, after
returning to the UK, set about revolutionising nursing. “Nightingale
influenced a new interest in household cleanliness as a goal that a good
wife and mother needs to instil in her family,” says Tomes.
The turn of the century saw the first popular
public health campaigns being launched around tuberculosis, says Tomes.
“Koch had shown that tuberculosis was not something you inherited from
your grandmother, but that your grandmother coughed on you, and that’s
why you got it.” The anti-tuberculosis movement was aimed at both adults
and schoolchildren. “You really were getting little kids taught these
rules about being clean and washing your hands.”
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| Joseph Lister and his assistants. | Photograph: Pictorial Press Ltd/Alamy |
Tomes adds: “People got totally phobic about
shaking hands or kissing each other when they understood that their
mouth, their skin and their hair had all these germs on them.” It’s one
reason, she says, why young men started eschewing beards at the turn of
the century. And why foods started being sold individually wrapped,
because of “this fear of germs and hands touching things”. But this
hygiene-centric era was short-lived.
The combination of public health messaging and
the development of vaccines and antibiotics in the early 20th century
saw death rates from bacterial diseases plummet. “The hyperattention to
this kind of cleanliness became less important,” says Tomes. “A laxity
crept in, I think, in healthcare and in everyday life after the second
world war.”
Tomes herself is a product of the
countercultural baby boomer generation, which rebelled against the rules
imposed by their parents’ and grandparents’ generations. “We thought
all this [hygiene] stuff was bourgeois nonsense,” she says. “Being a
hippy involved embracing the wonders of your microbial self.”
Sexually transmitted diseases started increasing
again in the 1970s. “People started to realise, well, these things can
come back if we get careless,” says Tomes. “But it was really with HIV
coming in the 1980s – a novel, deadly, sneaky kind of virus – that
everyone started to get hyper again about personal cleanliness.” Even
though, of course, HIV is transmitted by blood, semen, vaginal fluids
and breast milk, so hand hygiene isn’t a significant factor in
prevention, Tomes says we have been operating with a more aware mindset
in general since then. Hospital superbugs became a problem, “and now we
have these novel viruses coming pretty regularly, but we’re also getting
the re-emergence of bacterial diseases because of antibiotic
resistance”.
Actual handwashing compliance, pre-coronavirus,
was still worryingly low, however, in the public realm and in medical
care. In her book, Wahrman cites research undertaken with university
students in 2009, published in the American Journal of Infection
Control. “After urinating, 69 percent of women washed their hands, and
only 43 percent of men,” she says. “After defecation, 84 percent of
women and 78 percent of men washed their hands. And before eating – a
critical time to wash your hands – 10 percent of men and 7 percent of
women washed their hands.”
Wahrman’s mother died from a hospital-acquired
infection, so writing the book, she says, “was personal”. A study
conducted in a teaching hospital at East Tennessee State University in
2007 found that staff handwashing between attending patients in all
intensive care units (ICUs) had an overall compliance rate of just 54
percent. Staff in the paediatric ICU were much more conscientious, with
90 percent compliance, compared with just 35 percent in the adult ICU.
After intervention and training, however, the compliance rate in the
adult ICU was raised to 81 percent. We can only hope that the memes of
the Covid-19 pandemic will see similar or even better rises among the
public.
How effective is handwashing? Petra Klepac, an
assistant professor of infectious disease modelling at the London School
of Hygiene & Tropical Medicine, looked into this question in 2018
while predicting how a flu pandemic would spread in the UK, for the
documentary Contagion! The BBC Four Pandemic.
“We were looking for systematic reviews and
meta-analyses, and pooling the results from these studies,” she says. One review,
published in 2017, found significant effects from handwashing, compared
with nonsignificant effects from face-mask use. When Klepac and
colleagues drilled down into the highest quality data, gathered from a
clinical setting, with clinical diagnosis and a control group (who
didn’t increase hand hygiene) they discovered that if you washed your
hands five to 10 times more than usual, “that would reduce your risk by a
quarter”.
At the start of a pandemic, this is pretty much
all you’ve got. “You don’t have pharmaceutical interventions,” says
Klepac. “You don’t have a vaccine. This is why we’re looking at
nonpharmaceutical measures that are easily implemented.”
To Wahrman, this knowledge feels empowering.
“You can say to people: ‘Here’s one thing you can do to lower your
risk.’ It’s simple. It’s right there and doesn’t cost anything. Wash
your hands with soap before you touch your mouth, your nose or your
eyes. It’s empowering because it really does make a difference.”
See more at The Guardian
