COMMENTARY Economic & Political Weekly EPW NOVEMBER 28, 2015 vol l no 48 19 Hand-Washing and Public Health Lekha D Bhat, Kesavan Rajasekharan Nayar, Hisham Moosan, Sanjeev Nair, Muhammed Shaffi Lekha D Bhat (lekhabhatd@gmail.com) teaches at the Department of Social Work, Mizoram Central University; Kesavan Rajasekharan Nayar (krnayar@gmail. com) is at the Santhigiri Social Research Institute, Thiruvananthapuram; Hisham Moosan (drhishammd@gmail.com) is at the Department of Community Medicine, Medical College, Thiruvananthapuram; Sanjeev Nair (drsanjeevnair@gmail.com) teaches at the Department of Pulmonary Medicine, Medical College, Thiruvananthapuram; and Muhammed Shaffi ( fmshaffi@gmail.com) teaches at the Global Institute of Public Health, Thiruvananthapuram. The importance of hand-washing in personal and public hygiene has evolved over the centuries. While the market with its countless number of soaps and hand-wash products for personal hygiene with the accompanying advertising has created a false sense of security, it is community hygiene implemented through public health measures that is really effective in the battle against disease. I nfectious diseases remain a serious public health threat and hand-washing has emerged as one of the compo- nents of a package of public health tools to be used in preventing them. To be effective, the different components, including water supply, personal hy- giene, food security and sanitation have to function in coordination with one another. Cholera, typhoid and hepatitis A are some of the communicable diseases that are spread via the faecal–oral route. They occur when microorganisms enter the mouth through food, water and unhygienic toilet practices. Coignard et al (1998) observe that such infectious diseases are usually spread via hands. Compared to techno-centric packages and “magic bullets,” fingers and hands are outliers as far as public health is con- cerned, despite the fact that they have been at the centre of some of the major milestones in the history of medical practice. For instance, the significance of hand-washing in patient care was first recognised in the early 19th century by Semmelweis, a physician and epide- miologist (Timmreck 1998). Through observation of clinical practice, he noted that medical students who assisted in childbirth often did so after performing autopsies on patients who had died from sepsis (of bacterial origin), as a result of which maternal mortality was high. After instituting a strict policy of hand- washing, death rates fell considerably, demonstrating that the transfer of diseases could be reduced significantly using this simple hygienic practice. Labarraquee later provided evidence of the association between hand contami- nation and maternal mortality. Today, hand hygiene is considered to be a key measure in preventing the transmission of many communicable diseases. Impor- tant preventive strategies include hyg- iene education and appropriate hand- washing (Benenson 1995). According to the Centers for Disease Control ( CDC) (1985) there are four different levels of compliance in hand-washing: washing both hands with soap and rubbing them together to produce lather for 15 seconds (full compliance or level four); washing both hands with soap for less than 15 seconds (partial compliance or level three); rinsing both hands with water but no soap (minimal compliance or level two); and neither washing nor rinsing (non-compliance or level one). The CDC admits that in the absence of well- controlled studies, absolute indications for the frequency of hand-washing are not known. Public to Personal Hygiene Hygiene, especially adult hygiene as part of health practice, has its root in the Greek tradition wherein the goddess Hygieia was worshipped as the provider and protector of health. Prior to the modern period, all advice on hygiene assumed that only the wealthier classes could or should be following hygiene measures and practices. Indian mytho- logy related hygiene and cleanliness mainly to purity of mind rather than purity of body. It was only in the 18th century that ideas of hygiene started to reach the middle and lower class fami- lies as part of “well-mannered” behav- iour. Theories of contagion began to consider dirt as the reason behind the spread of diseases, modified with the advent of the germ theory identifying germs as the cause of various contagious diseases (Rosen 1958). It was also acknowledged that along with personal hygiene, other public health measures such as clean water and sanitation played an important role, and measures were accordingly taken in Western Europe. In the early 20th century, personal hygiene was focused on children and especially on bathing and hand-washing. In the first half of the century, attention was paid more to social hygiene than to mental and personal hygiene. From 1945 onwards however the focus shifted to personal hygiene with special emphasis on children. After the 1950s, hygiene was defined in a much narrower, indi- vidualised and clinical manner. Miner (1956) criticises the medical profession