One of the most simple and cost-effective ways to reduce pneumonia and diarrhea in children involves only two things: soap and water. A Lancet study published randomized control trial on the use of soap in Pakistan found that children under the age of 15 who were provided plain soap and hand-washing promotion had a pneumonia incidence 50 percent lower than children who did not receive such treatment. Diarrhea exceeded it with a 53 percent reduction in incidence. The evidence is clear, but the behavior change is still not there.
"In Senegal people do not wash their hands. A businessman believes that if he washes his hands it will wash away his money," says Dr. Myriam Sidibe, Social Director for Lifebouy. Sidibe has poured her public health focus into trying to make hand-washing a part of people's daily routine. With many people around the world able to access water adequate for hand-washing and soap, the intervention is a no-brainer. Better yet, the type of soap does not matter. In the same trial in Pakistan, the researchers concluded that anti-bacterial soap showed no significant difference from regular soap.
How can hand-washing become routine?
Affiliations are a powerful force explained Myriam. If people start seeing others washing their hands, they too will want to participate. Additionally she pointed to nurture as a key component to behavior change. If children are taught at a young age to wash their hands they will continue the habit as they grow older, teach their own children and so on.
I experienced this first hand in Western Kenya where hand-washing was a routine before and after meals as well as after using the bathroom. When we had meals it was the children who would many times run quickly to wash their hands. Restaurants would have basins with a faucet at the bottom and a bar of soap for hand-washing before meals. Customers were thorough. Some even looked like future doctors with the vigor used to scrub. Though a small observation, it was striking to see how hand-washing had become a routine part of life for Western Kenyans.
One challenge is the appearance of clean hands. When there is no visible dirt, a person might believe that his/her hands are clean. Discussing germs with pictures is hard if they cannot be seen. One way that Myriam addresses this problem is to take two people for a public demonstration. Each have powder poured on their hands. One is given soap to wash and the other only water. The two wash their hands and show the audience their seemingly clean hands. With a UV light, Myriam is able to show how the person who used soap has clean hands, but the person who only used water has dirty hands because residue remains that cannot be detected by the human eye.
What can we do in the United States?
"Everybody needs to wash their hands. You can help by making hand-washing with soap a norm in your own life," she advised. The changes will not necessarily be imposed by unilateral outside forces; rather it will require a social shift. Some might rush to provide free soap, but Myriam says that is not the real problem. "This is not necessarily about donor money. The goal is not to make soap a free thing. What needs to happen is for it to become a daily routine and it will become an unquestionable expense."
Saturday, the world celebrated Global Handwashing Day. On Thursday, I had the chance to speak with Myriam after she participated in the Guinness World Record for simultaneous hand-washing in Lagos, Nigera. There, 50,000 children gathered to wash their hands at the same time in an effort to raise awareness about the need for more people to wash their hands and get the chance to, as Myriam put it, "bring another world record to Africa." If you are in Washington D.C., you can go to the Global Handwashing Day Fair on Monday from Noon to 2 p.m. at 23rd and Eye St (The George Washington University George Ross Quad).
Luby, Stephen P., Mubina Agboatwalla, Daniel R Feikin, John Painter, Ward Billhimer MS, Arshad Altaf, Robert M Hoekstra. 2005. "Effect of handwashing on child health: a randomized controlled trial." The Lancet. Vol 366, July 16, 2005
Clasen T, Roberts I, Rabie T, Schmidt W-P, Cairncross S. 2006. "Interventions to improve water quality for preventing diarrhoea." (Cochrane Review). The Cochrane Library, Issue 3, 2006. Oxford.
Curtis, V. and Cairncross, S. 2003. "Effect of washing hands with soap on diarrhoea risk in the community: a systematic review". The Lancet Journal of Infectious Diseases, Vol. 3, May 2003, pp 275-281.
The Handwashing Handbook: A Guide for Developing a Hygiene Promotion Program to Increase Handwashing with Soap
WELL Fact Sheet: Health impact of hand-washing with soap Author: Jeroen Ensink Quality assurance: Val Curtis