The Hand-Washing Wars

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My neurologist father maintained that hand-washing was our family’s single greatest obligation to one another and to the world. “As you know, it’s the No. 1 way to prevent disease transmission,” Dr. Beauregard Lee Bercaw would say to my brother and me every single night before sitting down to dinner. “Your hands are clean, right?”

If we hemmed or hawed, we were banished to our bathroom to scrub as if we were surgeons, not children. Sometimes he’d stand behind us at the sink and provide a verbal inventory of ailments caused by poor sanitation and hygiene, throwing in the names of diseases he’d seen during his years spent practicing medicine in the tropics during the Vietnam War but found nowhere near our Florida home: “Meningitis … Hepatitis … Salmonella … Staphylococcus … Streptococcus … Giardiasis … Schistosomiasis … Cholera … Typhoid…”. His litanies would last for at least 30 seconds, so there was no need for either of us to mumble through “Happy Birthday” twice.


Dr. Beau Bercaw, left, at Clark Air Base in the Philippines in 1965.Credit…via Nancy Bercaw

But as the years passed, I grew increasingly numb to my father’s germ warfare tactics and ever more reluctant to follow his orders. By age 14, my focus was on improving my appearance with acne treatments and avoiding the watchful eyes of my father. By lingering in the bathroom, I was able to do both.

After a protracted cease-fire in the hand-washing wars, I was ambushed one afternoon when I was 15 by a loud pounding on the bathroom door. I opened it to see my father’s face twisted with fresh worries as he conveyed an ominous message in a matter-of-fact tone: “Kelly Dineen is going blind in her right eye because she didn’t wash her hands.”

Kelly, who was my best friend and the daughter of my father’s best friend, had woken up one morning with blurry vision in her left eye and, two days later, had lost most of her central vision in it. One of the early theories, propounded by my father, was that she’d contracted toxoplasmosis from cat feces, though later a leading eye doctor had diagnosed her as having an inflammatory disorder called multifocal choroiditis, a condition that had nothing to do with whether or not she had washed her hands.

It wasn’t until many years later, as a Peace Corps volunteer living in a rural village in Kenya, that I finally joined my father’s army of fanatical hand-washers. For the first few months in my rural village, I was plagued by diarrhea. Only by scrubbing methodically before every meal with boiled water and soap could I avoid getting sick. The correlation between cleanliness and health suddenly became clear and present in my life.

Now, amid the coronavirus pandemic and a gradual loosening of restrictions as shutdowns ease, I find myself lamenting what seems to be reluctance among some people — including my 16-year-old son — to wash their hands as if their lives depend upon it. Why do we have to keep reminding others to perform this one simple but potentially lifesaving act?

Dr. Leana Wen, an emergency physician and public health professor at George Washington University, who previously served as Baltimore’s Health Commissioner, told me that it’s indisputable that hand-washing saves lives. “In the hospital, hand hygiene is strictly enforced to reduce the spread of infections,” she says. “In the community, hand-washing is key to reducing person-to-person transmission of many illnesses, from respiratory illnesses like the cold and flu to food-borne illnesses like salmonella and cholera.”

Dr. Elaine Larson, professor emerita of nursing research and professor emerita of epidemiology at Columbia University, who is considered one of the world’s leading authorities on hand hygiene, agrees. In 1980, Dr. Larson wrote her dissertation on hand-washing and devoted the subsequent 40 years to studying infection prevention and spreading the message that “clean hands save lives.”

“I don’t think that people are reluctant, but every decision we make occurs because of habit as well as a quick, unconscious risk-benefit assessment, and then we ‘decide’ that we are safe,” she says. “Most people from childhood ‘learn’ that they can often omit hand hygiene with no consequences, so that reinforces that it is not an essential habit.”

But even in times like these, she says it’s “difficult to link the cause — not washing — and the effect — getting sick — when there is a time lag between the two and when it does not occur 100 percent of the time.” Another obstacle to normalizing hand-washing is what psychologists call “optimism bias,” which leads many of us to believe bad things are more likely to happen to others.

So is there any hope of convincing people that an ounce of prevention is worth a pound of cure, especially when it comes to Covid-19? Does hand-washing stand a chance of becoming part of the new normal, like wearing seatbelts did once we fully realized their impact on saving lives?

Dr. Larson explains that it’s always easier to change a system than to change behavior. “Cars now beep to remind us of wearing seatbelts. In hospitals, we are testing ways to notify staff when they need to wash, but those systems still need a lot of work,” she says. “Something like that may happen eventually in, for example, public restrooms and airports.”

  • Frequently Asked Questions and Advice

    Updated June 5, 2020

    • Does asymptomatic transmission of Covid-19 happen?

      So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • How does blood type influence coronavirus?

      A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • Will protests set off a second viral wave of coronavirus?

      Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

In 2009, the London School of Hygiene & Tropical Medicine studied the impact of intervention messaging in public bathrooms at rest areas along highways in England. Out of 14 different messages, “Is the person next to you washing their hands?” proved to be the most effective at changing behavior. So if we all start washing our hands more, others may be more likely to follow.

I followed up with my old friend Kelly Dineen, now a clinical psychologist with a private practice in Chicago, for her take on the situation. She suggested that those who remain indifferent or resistant to the cause should hang notes in their bathrooms and around the house to establish and cultivate the habit.

“Our minds are uniquely built to make things we do repetitively unconscious,” she says. “Think about brushing your teeth. Do you actually have to think about the many steps involved? No, you can brush your teeth and think about the day ahead. Similarly, if washing your hands is linked to mealtimes, going to the bathroom, and coming in the door, it becomes an automatic behavior.”

“Challenge yourself,” Dr. Dineen added. “This virus will remain with us. Don’t become its unwitting friend. Commit to one change,” she adds, “And if not for you, then for the people you love.”

If my father were still alive, he’d likely be knocking on bathroom doors everywhere — wearing a mask and surgical gloves, of course — to tell people that they can literally take matters into their own hands. I can hear him now: Thirty seconds of scrubbing from fingertips to forearms with hot water and soap could impact the course of a global pandemic. Why wouldn’t you do it?