This World Health Day, commitment to hand hygiene for all must prevail

A year ago, in April 2020, when India, like the rest of the world, was in lockdown, the emphasis was on preventative measures - handwashing with soap, mask use and physical distancing - to protect millions from the new infectious Coronavirus by slowing its transmission. A year and 12 million COVID-19 cases later, India faces a perilous second wave and is resolute in its commitment to protecting its vast population by embarking on the world’s largest vaccination drive. COVID-19 vaccines are an important step to end the pandemic, preventing infections and death, and restoring lives to the new normal. Alongside these promising vaccination efforts, we must emphasize and facilitate basic health-promoting and disease-preventing actions such as handwashing for all …. and here is why.

Handwashing with soap is a cost-effective public health intervention. While the Coronavirus pandemic propelled attention to and action on hand hygiene more than ever before, the protective powers of this behaviour extend well beyond this virus to other widespread infections. Handwashing with soap promotes good health and saves lives. It shields children from preventable death and sickness – regular washing of hands with soap and water can reduce pneumonia by 50%, acute respiratory infection by 16–23%, and the risk of endemic diarrhoea by up to 48%. Hand hygiene is vital in health care settings, as well,  and protects against healthcare-associated infections, potentially contributing to reductions in antimicrobial resistance – two mounting concerns in health facilities in India and globally. Perhaps most importantly, enabling the widescale practice of hand hygiene can help reduce inequalities. Socio-economically disadvantaged communities and households are at greater risk of adverse health outcomes than those from higher income levels, lacking access to basic resources, including safe sanitation and clean water. Evidence from India points to improved health and lowered out of pocket expenditure for health care needs when families have improved sanitation. Along the same lines, strikingly,  hand hygiene has been found to bring economic benefits, too – research suggests a 15:1 return on investment in hand hygiene.

Given these benefits, let us turn to what is needed for handwashing. Cleaning hands involves washing hands thoroughly with soap and water at times when hands are most likely to be contaminated with germs or soiled with dirt – after defecation, using the toilet and cleaning a child’s bottom; before cooking, eating and feeding children; after sneezing, coughing; before, during and after attending to a sick person; and after engaging in any contaminating task. Cleaning with soap is essential, as soap destroys or inactivates pathogens. Any soap works –regular bar soap, detergent powder, and even soapy water (when made properly). Hand hygiene also requires the understanding that this behaviour is advantageous.

Hand hygiene, seemingly simple and beneficial, is challenging to practice and institutionalize. Several hurdles exist, most strikingly, the absence of handwashing infrastructure (for instance, a sink or designated place for washing hands), paucity of water and soap, low levels of awareness of the protective benefits of handwashing, and the reality that handwashing is simply not established and invested in as a behaviour that has wide-ranging health, social and economic advantages.   

The barriers to handwashing are not insurmountable. Indeed, the first phase of the pandemic brought to the forefront low-cost, low-tech and context-appropriate solutions for handwashing stations for rural and urban households, schools, public places, and worksites. Contactless or handsfree soap and water dispensing units were designed and widely established, and innovations were implemented such as WaterAid India’s wash on wheels (autos fitted with a handwashing unit for use of drivers and passengers). Solutions for areas with scarce water supply have been tried, such as the construction of rainwater harvesting structures connected to handwashing stations. Many such solutions and innovations were tried, responding to different contexts, needs and constraints. These now need to be identified, collated, studied for their functionality, suitability and replicability, and scaled up accordingly at the household level, in educational institutions, health care facilities, worksites, public spaces, at the very minimum.  Attention to solutions for vulnerable areas (e.g., water-stressed areas, disaster-prone areas) and for vulnerable and marginalized groups (for instance - migrant workers, the homeless, low-income settlements) is vital to enable those who are most susceptible to poor health to engage in this healthful practice. The promotion of hand hygiene requires significant rethinking. Early pandemic messaging undoubtedly facilitated handwashing practices as many of us were fearful of the pandemic and its unknown consequences. Evidence suggests that fear-based messaging or messaging tapping into fears will increase awareness, but may not result in sustained practice and ingrained or long-lasting behaviours. Our messaging for hand hygiene must evolve and position hand hygiene as essential for good health and disease prevention (including and beyond COVID-19), tap into behavioural drivers that reinforce the personal relevance of this action, and establish it as a social norm for all.

Alongside infrastructure and promotion, commitment to and investment in hand hygiene is required – not as an additional, siloed intervention or program, but as an essential component of health, nutrition, education, rural and urban development initiatives. Such integration will enable sustained action on hand hygiene, and establish its connection with our larger priorities for improved health and economic development. 

And as India and the world continue the fight against Coronavirus, handwashing continues to be relevant for COVID-19 prevention, in conjunction with vaccination efforts. Universal vaccination will take time, people will get infected in the interim, and virus mutations will necessitate vaccine alterations. Hand hygiene remains an unchanging constant companion – an act, given that the basics of water, soap and understanding are in place, will save millions - in money and in human life.