The Trump Administration has committed to reopening the economy at all costs, the White House coronavirus task force has vanished from view, the Centers for Disease Control and Prevention was silenced for three full months—and a coronavirus vaccine is more than a year away. As the United States opens up piecemeal from lockdown, what happens next in the pandemic is being left up to the decisions each of us make: to observe social distancing, to wear a mask, and most of all, to wash your hands. The last of these is the simplest to do, and was the first piece of pandemic health care advice most of us got. But as the people who do it most—health care workers—can testify, it’s challenging to do it consistently and well.
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It’s been 174 years since obstetrician Ignaz Semmelweis noticed that two wards in a Vienna maternity hospital had strikingly different rates of post-childbirth infections—and that what made the difference was whether or not the health care personnel taking care of the new mothers washed their hands before examining them. It’s been two decades since an explosion of superbug and C. diff epidemics demonstrated how many of the 2 million infections that occur in hospitals each year are passed between patients by health care workers. Handwashing in health care is pushed by the CDC, it’s a favorite message of the World Health Organization, and it’s the backdrop to the entire medical specialty of infection prevention and control.
Yet it’s a surprisingly difficult thing to get health care workers to do. Even though they’re bombarded with messages every day of their working lives, the CDC estimates that health care workers clean their hands on average less than half the times they should. That’s despite knowing that somewhere between 50 and 70 percent of the infections that occur in health care settings in the US each year could be prevented if hand hygiene was followed more faithfully. “Hand hygiene is the bane of our existence,” says Saskia Popescu, an infectious disease preventionist and epidemiologist in Phoenix. “No one gets it right all the time.”
This is an important thing to think about, because as we move into Covid-19’s new normal, all us civilians will need to routinely do things that even professionals find hard. And we’ll mostly be making the decisions to do them (or not) out of our own volition, because there’s not yet a public health campaign—the kind that puts commercials between TV shows and signs on bus shelters—to remind us. A good portion of the population may not even have a memory of what those are like: The seat belt campaigns of the 1980s and the condom-use campaigns of the 1990s are a generation in the past.
As the campaign to improve hygiene in medical settings shows, figuring out what prompts people to act is a work in progress. People who spend their professional lives in infection control say that its failures and successes offer some important lessons for getting the rest of us to protect each other. The first thing to do, oddly enough, may be to admit the failure—that is, to make it clear that what people are being asked to do is outside of their normal behaviors and therefore hard. The second is to recognize that not everyone fails to comply for the same reason.
For example, for some health care workers, the problem is lack of knowledge or missing out on training, says Diane Cullen, who is associate director of standards interpretation at the Joint Commission, a nonprofit organization which audits and accredits health care organizations based on how well they prevent infections and promote patient safety. For others, it’s not agreeing with a policy. “Lack of buy-in,” Cullen calls it: “A staff member might have been trained in hand hygiene but is too busy to do it, or doesn’t feel they need to do it as often as the regulations say.” Still others might not bother with washing their hands or lathering up with alcohol gel because they’re not concerned about the consequences if they’re found out—either punishment from their workplace or disapprobation from their peers.
Health care workers have been working on these challenges in a low-key way for a long time—and they have some answers that might be applicable to preventing the spread of Covid-19. The education part is easy, maybe: You tell people how important the action is—but to make it stick, you have to tell them not only over and over again, but in as many different ways as you can manage. “You have to continuously change and evolve your messaging and your tactics, because it becomes white noise very quickly,” Popescu says. “People become accustomed to the reminders, the flyers, the messages on their computers, and just don’t see them any more.”
You also can’t rely on people complying just because they know what to do. Colum Dunne, director of the Centre for Interventions in Infection, Inflammation, and Immunity at the University of Limerick, led a long-term study of how medical, nursing, and health students viewed hand hygiene as they went through their school and training and landed jobs in health care. “When they’re in college, their knowledge, attitudes, and awareness are all there. They are keen,” he says. “But as they stay in their career longer, they become less compliant. People are human: They’re busy, they have responsibilities, and they become jaded with the message.”
The experts acknowledge that people disagreeing with rules, or not feeling they apply, is a harder problem to crack. The health care industry tackled that, in part, by adopting a concept that originates in aviation: guaranteeing that anyone is allowed to speak up to prevent someone else from making a mistake, even if the person speaking up occupies a low position and the person doing wrong is highly placed. (The aviation version, known as crew resource management, originates from what is still history’s worst civilian air disaster: a runway collision between two Boeing 747s in 1977 on the island of Tenerife, which killed 583 people—and might have been avoided if one of the pilots had listened to warnings from a crew member who was junior to him.)
Cullen says social pressure—to prevent dangerous actions or to reinforce positive ones—can go a long way. After weeks of lockdown, she went out last week for her first post-Covid haircut. In the salon she visited in the suburbs of Chicago, everyone was masked, and at every station, there was a bottle of hand sanitizer. “And because it was visible, everyone realized it was important, and everyone used it,” Cullen says.
There are other aspects of hand hygiene campaigns that can show the post-Covid world what works, like having products that are pleasant to use—say, hand gels that are soothing instead of skin-chapping—and making them easy for people to access. (The hospital version of that is putting the hand gel dispensers near the opportunities for picking up or depositing superbugs: by the elevator, the telephone, and the doors to patient rooms.) Emphasizing empathy may work better than threatening people with risk: Health care workers may skip lathering up because they don’t feel at risk personally, but they may be willing to do it one more time if they understand they are risking the health of a patient who depends on them.
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But the most influential factor of all may also be the one that looks the bleakest for the US: role modeling provided by leaders. Health care organizations have had sustained success with hand hygiene campaigns when people at the top—chairpersons, presidents, CEOs—have taken it on as a personal crusade.
We can’t really tell how often government leaders wash their hands, but we have a good proxy for how supportive they are of Covid-19 public health measures: how much they support mask wearing. Of course, wearing a mask isn’t a foolproof defense against spreading the virus, but though the science is still evolving, it appears to lower the odds that an infected person will cough or breathe germs onto others. And even without rock-solid science, masks have become a signal of social cohesion, a visual shorthand for whether people take Covid-19 seriously.
Yet the guidance leaders are giving is all over the place. In Virginia and New York, wearing a mask is mandatory outside your house for most situations. In Ohio, mask-wearing was mandatory, until the state’s governor was forced to back down. And in Georgia, Governor Brian Kemp refused to require them, saying: “We’re not a nanny state here.”
President Donald Trump, of course, mostly refuses to wear a mask, and Vice President Mike Pence and several cabinet members have been photographed mixing with the public without wearing them too. (Former vice president Joe Biden, the presumptive Democratic nominee, observed Memorial Day in public wearing a mask.)
“To change a culture, you need leadership buy-in, modeling a behavior and embracing it,” Cullen says. But it may not be necessary to have that example come from the White House if other leaders take the responsibility instead, Cullen says. “It can be a leader at any level,” she adds. “A local council member, the mayor, the fire chief. What’s important is that someone who is respected in their community shows that they have a stake in the game.”
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