Wednesday, March 26, 2008

AMERICAN MEDICINE’S HANDWASHING OBSESSION- Yet another good concept taken to irrational excess.

Recently US Medical leaders from the hospital sector and the public health community have been imploring hospital employees and the public to spend much more time washing their hands.

I knew we were in trouble however with this concept – essentially a good one when applied rationally – when the Commissioner of Health for my home state of Pennsylvania said at a public meeting that I attended last year that he was considering giving up the practice of shaking hands with people especially during the winter months. Whoaaaa???

And where money can be made an entire "handwashing industry" has sprung up including training modules,educational materials and a variety of handwashing products.

Now in hospitals we have the very real and very tragic problem of increasing number of hospital acquired infections(HAIs)which undoubtedly could be partially mitigated by more handwashing especially by staff so a to avoid cross transmission of pathogenic organisms between patients. But even in this situation hospitals would do well to focus on other underlying reasons for increased hospital based infections such as the overuse of antibiotics and other medications and a variety of patient host resistance factors such as aging, nutritional status, the presence of underlying diseases and immuno-suppressed states.

My basic reasons for positing that we are perhaps overly obsessed with handwashing are twofold-

-Firstly I have believed for decades that infectious disease specialists who tend to populate our public health agencies including our own CDC focus far too much on organisms and their pathogenicity exclusive of considering host resistance or general environmental factors in disease causation. I have always been surprised by this bias toward organism vs. host because I thought that the interaction between the two was a well established principle. As truly remarkable the contributions of Louis Pasteur were in establishing the Germ Theory of Medicine it would not hurt to re- look at two of Pasteur’s contemporaries Claude Bernard and Antoine Bechamp who held a more holistic scientific view of disease causation. Yet because of the miracles of the infectious disease model and the incredible effectiveness of vaccines and antibiotics we ran successfully with this model in my opinion to excess. Now the excess is “biting us back”.

On a personal note in 1991 I wrote a letter about the common cold that was published in a local medical society journal which posited that the adenovirus theory of the common cold wasn’t getting us very far and that we just might want to look at other possible factors. I was in part validated by the work of Dr.Sheldon Cohen of the University of Pittsburg who published rigorous scientific studies on the relationship of stress to the common cold.(and other diseases)

-Secondly I have become intrigued with what has become known as "The Hygiene Hypothesis" first proposed in 1989 by David P Strachan in an article in the British Medical Journal(BMJ)which fundamentally posits that possibly a large number of immunologic disorders such as allergies and asthma might actually be caused by or contributed to by the excesses of a clean environment especially during infancy and childhood. Much more work needs to be done and I am not suggesting that we all "consume a daily portion of dirt" but expert epidemiologists, allergists and immunologists are taking the theory seriously. Perhaps the infectious disease specialty community would benefit from considering this theory in their deliberations about the frequency and intensity of handwashing?

Now I give full credit to Viennese physician Ignaz Semmelweis who in 1857 introduced the simple principle that students and physicians in the Vienna General Hospital must clean their hands with a chlorine solution between patients in the obstetrics clinic and after visiting the hospital morgue thus reducing the deadly disease known as puerperal fever. But ironically Semmelwies’ handwashing recommendation was stimulated by noting that Viennese mothers who gave birth at home attended to by midwives had a much lower rate of this disease.

Anyway we have come a long way since the days of the “Father of Handwashing” Semmelweis and much good information can be gleaned by the CDCs current recommendations for both handwashing in health care settings and
handwashing for the general populations

I can’t help but think however that washing of ones hands is only a small part of a comprehensive approach to reducing hospital based infections and reducing the spread of common diseases like the flu or the common cold.

Using some poetic license- not very popular at all with bio-medical scientists- I cannot help but wonder that on some unconscious level whether we handwashers are like Shakespeare's Lady Macbeth trying to cleanse way our collective guilt about where we have taken contemporary modern medicine- in part because we take good scientific principles to excess. Handwashing is only one example of this phenomenon of excess.

And the next time I hear a health care leader announcing publically that he/she is giving up on the shaking of hands as a warm greeting to others remind me once more to question authority.

Dr. Rick Lippin
Southampton, Pa


Blogger Robin Hanson said...

You haven't actually pointed to any evidence that we wash our hands too much.

5:22 AM  
Anonymous Dr. Rick Lippin said...


Correct. I don't think the evidence exists? Most of the handwashing literature as I read it is done by reductionistic scientists who do not consider the confounding variables I might consider were I doing a study.


Rick Lippin

6:23 AM  
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Blogger Brian said...

Respectfully, it was difficult to read this post because of the poor punctuation. You might want to get someone to proofread for you.

7:22 PM  
Anonymous Anonymous said...

Handwashing is a good way to prevent disease transmission, but it's half the equation. I think you are right in suggesting that just handwashing, without throwing away all the germicidal sprays and napkins used in homes, etc. won't accomplish much, since it completely fails to address the issue of people having compromised immune systems from (1) lack of exposure to run of the mill germs; (2) assumptions that the use of gloves alone is sufficient; (3) over use of antibiotics in food, for viral infections, etc. If you don't treat all three, you won't get to the root of the problem.

The healthcare system is broken for patients and providers alike. Advertising pharmaceuticals should be stopped immediately. Wellness need to be taught and encouraged. More evidence based medicine needs to be practiced, and newer doesn't always mean better results.

In the end, medicine is as much an art as a science many times. It's a partnership between physician and patient for the benefit (and not just financial) of both.

Anne Rutherford

12:11 PM  
Anonymous CW Kleas said...

Thank you for shedding light on this issue. This is a policy which has taken on a life of its own.

One thing which seems to get ingnored is how dirty beds, floors, stethescopes, blood pressure cuffs, etc. can get and how infrequently or inadequately they are cleaned.

And as you mentioned, host factors are important as well. With virulent resistant organisms now in the community, which infections in our hospitalized patients are due to emergence of infection after compromise of the host by their illness or by our treatments?

While handwashing is important, reducing the real problems to a single simplistic issue misses the mark and risks generating a false sense of security.

9:46 AM  
Anonymous Anonymous said...

Hospital Acquired Infection is the number four killer in America, more than AIDS, breast cancer and car accidents combined.

This irrational attack on "irrational" handwashing is based mostly on uninformed speculation.This is a totally irresponsible piece that creates a baseless impression that reduces the crucial role hands can play in cross contamination, especially with deadly staph infections. There is an implied reduction of the importance of hand washing which is already a deeply neglected practice in the medical profession. The fact that it is only one factor does not in any way diminish it's importance.

11:22 PM  
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10:49 AM  
Anonymous girl said...

Anonymous -- It's true that hand washing is already neglected in hospitals, but I don't believe that ignorance is a reason. If there's a risk that making noise about hand washing substitutes for (a) practically facilitating hand washing (with convenient stations, adequate time, checklists, whatever), (b) addressing the issue of hospital acquired infections more broadly, (c) actually washing hands, I don't see the harm in questioning NOT the value of hand washing, but the noise surrounding it!

6:03 PM  

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