Let Me See You Wash Your Hands!

One of the heroes of SuperFreakonomics is Ignatz Semmelweis — who crunched numbers in the 1840’s to champion the benefits of doctors washing their hands.

“The reason why unusual interventions are necessary is simply because voluntarism wasn’t working.”

(I’ve written a bit about him myself and, for some odd reason, I just love to pronounce “Ignatz” out loud.) It has taken the medical profession a long, long time to get religion on hand sanitization.

But there is good news: Clean Hand programs are now the norm at hospitals. SuperFreakonomics explains how hand-hygiene compliance at Cedars-Sinai Medical Center “shot up to nearly 100 percent” after the hospital started using disgusting pictures of the bacteria found on the palm prints of physicians as screensavers. I can verify that other hospitals are copying this solution. A couple of weeks ago, one of my coauthors had a health scare and was hospitalized for a night in New Haven. Her hospital ward was plastered with color photocopies of disgusting, bacteria-laden palm cultures.

I’m also impressed with the increasing practice of hand-sanitation in front of the patient. Many health care workers show you that they have just applied Purell as they are coming in to examine you. We’re slowly getting to the point where patients might start calling out doctors who don’t sanitize in their presence. Indeed, in addition to the disgusting hand cultures, hospitals might do well to post notices asking patients to challenge anyone who tries to treat without sanitizing in their presence. (This idea is a bit like the restaurants that say “your food is free if you are not given a receipt.”)

The reason why unusual interventions are necessary is simply because voluntarism wasn’t working. Giving health care workers the unaided choice resulted in too many people bypassing the hand-washing opportunity. Sadly, hand sanitation is a classic non-durable precaution. To be effective, it needs to be done repeatedly. Psychologically, it needs to become routine for us to have a chance of making the practice stick. (That’s how I finally got in the habit of using a seat-belt.)

Having won the day with hospitals, we should turn our attention toward schools. Sadly, most schools are at best stuck in voluntary regimes where students can wash their hands if they want to. My concern is that not enough students avail themselves of this option. Even if 80 percent regularly choose to sanitize (a pipe dream), the persistence of a recalcitrant 20 percent might undermine the public health benefits of sanitation.

Here’s a minibleg: If your school or place of business has public hand-sanitizers, I’d love to learn how often you have to refill the dispensers. If we know the rate of use and the number of people in the building, we can know the average rate of sanitation. I bet we’d find that the rate of sanitation would be very low. (I bet we’d find a similar result if we compared toilet paper use to soap use in school toilets. We should be very scared if there are 100 sheets of toilet paper used for every dose of hand soap.)

Schools should experiment with mandating routine, public hand sanitation. As a beginning, they might put Purell dispensers in science class and ask the teachers to make sure that their students dose their hands at the end of class.

Mandating hand-sanitation might reduce sick days by as much as 20 percent. In fact, that’s what this 2002 study of 18 elementary schools (located in Delaware, Ohio, Tennessee, and California) found. The study protocol required multiple sanitations per day:

[T]he students were instructed to also use the waterless alcohol gel hand sanitizer when entering and leaving the classroom, especially first thing in the morning, before and after lunch, after recesses, after use of the restroom, and before going home. Students were also encouraged to use the sanitizer when they sneezed or coughed.

Crucially, the study made teachers responsible for ensuring that the protocol was followed.

Compared with paired control group schools, students who were forced to clean their hands ended up with 19.8 percent fewer sick days (the full article is behind a firewall here; similar studies are abstracted here). And teachers’ absenteeism dropped by 10.1 percent. These figures ignore the beneficial effects on moms and dads and others who probably got sick less too.

As our nation suffers through another flu season, the spirit of Ignatz Semmelweis calls out to us across the decades for less discretionary hand sanitation.


ACW

"Indeed, ... hospitals might do well to post notices asking patients to challenge anyone who tries to treat without sanitizing in their presence. (This idea is a bit like the restaurants that say “your food is free if you are not given a receipt.”)"

Better yet, hospitals might adopt a policy that your treatment is free if your healthcare provider (doctor, nurse, aide, whoever) does not sanitise in your presence - and the compensation of the provider is docked accordingly. I guarantee 100 percent compliance almost overnight.

Will

My elementary schools/middle school/high school rarely even refilled the soap dispensers. Talk about a disincentive to wash your hands! Paper towels were often in short supply, as well.

-Will

Robin

What about the dangers of breeding antiseptic resistant germs due to over use of sanitizer products?

zadig

Studies ? results sometimes. Remember when doctor's neckties were found to contain germs? How many hospitals have banned neckties since then? Any?

I remember asking a doctor about it (who was wearing a tie) and he said "Oh, I just wouldn't feel professional without it." Good luck clearing out that potential source of infection.

Measure

How did this Ignatz guy know, without germ theory, that washing hands in a chlorine bath would work?

How he got to that solution seemed a bit glossed-over in the Superfreakonomics book. Did he try a variety of handwash formulas to find one that worke?

Eric M. Jones

My local hospital visits always result in a scabies infestation (an underdiagnosed disease), but hand-sanitizers kill them as well.

For years I have been surprised by the lack of interest the medical community has shown in stamping out nosocomial infections by using door knobs and push plates made of silver (plated) or brass or copper. The standard stainless steel or anodized aluminum has an oxide layer that supports bacterial growth. They wash the floors, but tests have shown this has little effect--better to wash the doors.

Still I should be grateful for all the diseases I have had that give me immunity I suppose...in these..."The Days of Swine Neuroses....la dah di dah dah..."

Caliphilosopher

I'm with Robin on this one. Why not just make hand washing mandatory instead of mandatory sanitizer gel?

KP

Robin, studies appear to show that alcohol-based sanitizers do not breed resistance. Alcohol-based sanitizers are also the most effective, but the key is to have them located EVERYWHERE so compliance is easy.

Ed

How do you build up a strong immune system if you're not exposed to pathogens?

Beth

All of my son's regular classes (a large public middle school in Atlanta) have the large Purell dispensers mounted just inside the door, and the teacher calls out a reminder to wash their hands on the way in and the way out, but compliance is voluntary.

Doug

Most hand sanitizers use ethyl alcohol. There are several articles examining this, but it comes down to the fact that the biological effects of ethyl alcohol are not possible to 'resist'. It tears bacteria apart. It would injure you as well except for your dead layer of epidermal cells.

rda

In schools, there's also the danger of misuse of the product, which can be dangerous. That stuff is flammable! It can also be a skin and respiratory sensitizer.

I wish we could at least guarantee access to clean, usable bathrooms in schools in the US. There've been plenty of stories about high and junior high schools with bathrooms kept locked all or most of the time because the school can't deal with the vandalism, drug use and assault that occur in there. And the bathrooms are often short of paper, soap and hot water even when they're open and safe for students to use.

noah

Soap and water is a lot more effective than hand sanitizer AND has the added benefit of not selecting antibiotic resistant bacteria.

Nate

Isopropyl alcohol, which is the active ingredient in hand sanitizers, evaporates too quickly (in seconds) for microorganisms to have a chance to develop resistence. Or at least that's what I've read about it.

Ben

"Better yet, hospitals might adopt a policy that your treatment is free if your healthcare provider (doctor, nurse, aide, whoever) does not sanitise in your presence - and the compensation of the provider is docked accordingly. I guarantee 100 percent compliance almost overnight."

The doctor bills the patient directly - the hospital is not an intermediary in this transaction, though they do bill separately for the use of the room.

Nate

"Remember when doctor's neckties were found to contain germs? How many hospitals have banned neckties since then? Any?"

I'll bet doctors' pants contain germs too. Hope you're not proposing we get rid of those.

David Chowes, New York City

I thought it was U. S. Army physician Dr. Lister who suggested this practice and was laughed at by his peers.

Am I wrong?

Chet Longley

Does anyone have links to the pictures of disgusting bacteria cultures? I would love to post some of them in the bathrooms at my building.

Jim

There's a kid in my son's class who's allergic to something in the hand sanitizers, and it's more than just contact. His eyes start to water when someone uses it, so there's none in my son's classroom.

zadig

I'll bet doctors' pants contain germs too. Hope you're not proposing we get rid of those.

Pants get laundered far more often than neckties. Did you really not already know that? Nothing that isn't cleaned regularly should be allowed around patients.

If a doctor wants to show that his necktie has been cleaned since the last wearing, I'd say go ahead and wear it. Otherwise, forget it.