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Recently I spent time with a relative in the ICU, the Intensive Care Unit at my local hospital. In the ten days I kept vigil until his recovery, the hospital staff kept his room sterile. Every time the room was entered a new pair of gloves was put on. Blood pressure and other monitors were wiped down when entering and leaving the room. The floor and bed rails were cleaned often. For the short time he was considered contagious, we all put on paper aprons when entering, discarding when leaving. There were four trash receptacles—one for needles and sharps, one for soiled linen, one for bio-contaminated equipment like tubes and wipes, and one for plain refuse. Staff efforts at keeping the room sterile were impressive. 

Poor Dr. Semmelweis would have been very pleased. In 1847 he tried to convince doctors in his Viennese maternity ward to simply wash their hands. He was convinced doctors were inadvertently carrying infection into the ward where mothers were dying of puerperal fever. It is thought that Jane Seymour, the third wife of King Henry VIII was possibly the most famous victim of puerperal fever. In 1537, she died two weeks after giving birth to Henry's only surviving son, the future Edward VI of England. Mary Wollstonecraft Shelley (who wrote Frankenstein), also died of this disease shortly after giving birth. Ignaz Semmelweis’ idea of hand washing was considered bizarre for decades. Doctors then believed that infections were due to “miasmas” or “bad air,” or to the imbalance of humors within a patient's body that could be relieved by bloodletting. Doctors who performed autopsies were revered because they were considered to be actively investigating the causes of sickness. Their colleagues believed that the dirtier the doctor, the better the doctor; doctors were proud to display their coats stiff with blood from the last autopsy or surgery they performed as they headed for the maternity ward. The idea that the doctor could be the agent of disease transmission was considered preposterous and wholly rejected. 

But others besides Semmelweis advocated hand washing. British nurse Florence Nightingale at a military hospital in Turkey in 1854 was shocked to discover that nearly ten times as many soldiers fighting the Crimean War died from infections and diseases than in battle. Nightingale brought in soap, towels, fresh sheets, and she insisted on hand washing. “Every nurse ought to be careful to wash her hands very frequently during the day,” she later wrote in her book Notes on Nursing (1859). 

In the United States in 1855, Oliver Wendell Holmes also found that physicians with unwashed hands were responsible for transmitting puerperal fever from patient to patient. He was promptly attacked by the leading Philadelphia obstetrician, Charles D. Meigs, who declared that “Doctors are gentlemen, and gentlemen’s hands are clean…any practitioner who met with cases of puerperal fever was simply “unlucky…I prefer to attribute them to accident, or Providence.” Unfortunately, Semmelweis was dead for 20 years before his findings on hand washing gained acceptance. 

Hand washing: Not a New Idea 

As early as 2800 BC ancient Babylonians used soap; Egyptians (1500 BC) bathed with soap-like substances made from plants combined with animal and vegetable oils. In ancient Greece, hands were cleaned using mud and ashes. In developing countries today where soap is not available, mud and ashes are still used. Among American Indians, yucca root was used for soap as it forms a lather. Many religions require hand and foot washing before entering religious sites and at certain rituals. 

The discovery of germs 

From long before Biblical times, it was known that diseases were contagious. In the 1860s, however, Louis Pasteur and Robert Koch showed that microbes could cause diseases such as tuberculosis and smallpox; their germ theory explained how diseases were transmitted and they developed vaccines that could prevent disease. Pasteur also connected his germ theory of disease with Semmelweis’ data and worked to making hand washing more popular. In 1865, Joseph Lister demonstrated that hand washing with antiseptic carbolic acid improved the outcome of surgeries. 

As germ theory took hold, hand washing became a cause celebre. Homes had wash basins and ewers holding water in their bedrooms; houses built in the 1890’s had basins with plumbing built into every bedroom with the water closet (toilet) down the hall. In one very old restaurant in Hawaii, there still is a wash basin at the front door for people to use before entering the dining room. Lifebuoy, a carbolic soap, was introduced by Lever Brothers in 1894 in Victorian England to combat cholera; it advertised its soap with a picture of a sailor rescued by a life buoy and the slogans “For Saving Life” and “Ending infections.” Nurses stationed in public schools taught children to wash their hands before meals. Fear of germ contamination generated laws that prevented food handlers from touching money which was known to be dirty. Even books in the public library were thought by some to be possibly contaminated because of use by many people. 

Today it is known that diseases most often transmitted and prevented by hand washing are flu, colds and diarrhea. In developing countries, hand washing with soap also protects against pandemic flu, SARS, trachoma and parasitic worm infections. Hand washing keeps children in school; it reduces infections that mothers and babies may contract during delivery and postnatal care. Hand washing by parents and midwives is found to prevent infant mortality. 

Dr. Myriam Sidibe of Mali, Africa, founded International Hand Washing Day, Oct 15. She partners with organizations such as UNICEF, the World Bank, PSI, Oxfam, MCHIP and USAID to educate people about the importance of hand washing with soap because washing with soap and water can save lives. She recently gave a TED talk on how washing with soap, a simple public health measure, prevents childhood diseases. (https://www.ted.com/talks/myriam_sidibe_the_simple_power_of_hand_washing) 

Now when entering many health facilities, supermarkets and restaurants, alcohol wipe dispensers are often available. Public lavatories provide soaps and hand drying. Portable toilets at events often include hand-washing basins.  

The Center for Disease Control lists times that hands should be washed: 

• Before, during, and after preparing food
• Before eating food
• After using the toilet
• After changing diapers or cleaning up a child who has used the toilet
• After blowing your nose, coughing, or sneezing
• Before and after caring for someone who is sick
• Before and after treating a cut or wound
• After touching an animal, animal feed, or animal waste
• After handling pet food or pet treats
• After touching garbage

Among the great public health achievements of the 20th Century are control of infectious diseases, improvements in maternal and child health, and improving food safety. Hand washing was important to these successes. Public health achievements that we enjoy every day are 

• Vaccinations to reduce infectious diseases
• Control of infectious diseases
• Food Safety
• Improvements in maternal and child health
• Decline in death from cardiovascular disease
• Family planning
• Fluoridation of drinking water to reduce dental cavities
• Reductions in prevalence of tobacco use
• Improved motor vehicle safety
• Safer workplaces

These public health successes have increased our life expectancy from about age 40 in 1850 to age 78 in 2019. Infant mortality rates have declined from 181.3 deaths per 1,000 live births in 1900 to 5.8 in 2017. 

Today, we expect people to wash their hands frequently. Laws regarding food handlers include hand washing before, after and during food preparation. By washing their hands properly with soap, people can prevent the spread of diseases and infections and live longer and healthier lives. Soap up, everyone!