By Gideon Lasco

In the Philippines, as in numerous other regions, the demand for hand sanitizers has surged. Since January, dispensers and bottles have become ubiquitous—found in airports, schools, restaurants, and personal bags. In the country's largest shopping mall chain, SM, large hand sanitizer stations await customers at security checkpoints, with signs proclaiming, "This is a sanitized zone. Thank you for using the provided disinfectant."

With the initiation of the enhanced community quarantine on March 17, hand sanitizer also became a staple at road checkpoints. Even though many stores in malls have closed, shoppers are still able to visit supermarket outlets, where staff spray their hands with alcohol before entering.

This upsurge in sanitizer usage is hardly surprising. The COVID-19 pandemic has driven individuals globally to stockpile hand sanitizers, soaps, and antibacterial wipes. What is unexpected is that prior to the outbreak's arrival in Western nations, the trend was moving in the opposite direction.

Over the past decade, concerns have arisen about the potential dangers of an obsession with eliminating germs, including the risk of developing antibiotic-resistant superbugs. This shift has certainly influenced people's hand hygiene practices.

In recent years, the U.S. Food and Drug Administration (FDA) has cautioned against the use of antibacterial soap, which has not shown to be more effective than regular soap in preventing illness and may even pose health risks. After it was found that common antibacterial soap ingredients—especially triclosan and triclocarban—could disrupt hormones in animal studies and promote antibiotic resistance, the FDA banned these substances in 2016, replacing them with safer alternatives.

However, when soap and water aren't available, alcohol-based sanitizers and wipes are deemed acceptable alternatives due to their efficacy against certain viruses, including coronaviruses, as well as bacteria.

Yet even before the pandemic, some health professionals advised reducing the use of alcohol-based sanitizers. This was partly due to some bacteria developing increased alcohol tolerance and partly because of concerns regarding the potential harm sanitizers could inflict on the microbiome—the vast community of microbes essential for a healthy immune system and digestion residing in and on the human body.

In recent years, numerous researchers have voiced worries that over-sanitized environments are linked to rising instances of autoimmune disorders, allergies, and inflammatory diseases. While this "hygiene hypothesis" remains contentious, there is a clear recognition among scientists and the public that certain microbes can be beneficial.

Yet amid the COVID-19 crisis, the focus on hand sanitizing has intensified, with many people struggling to find sanitizer in stores or online. Individuals who previously sought to enhance their microbiome diversity by interacting with pets now find themselves disinfecting their sanitizer bottles with wipes.

To comprehend this abrupt shift, it's enlightening to delve into the intricate history and anthropology of hand hygiene. What drives handwashing behaviors? How do beliefs regarding sanitizers and microbes play a role? How have past epidemics influenced these attitudes? And what might the future of hand hygiene look like post-COVID?

Historically, even before the 19th-century revelation that germs cause illness, handwashing held significant hygienic and symbolic value across many cultures and religious practices. For example, the Prophet Muhammad instructed Muslims to wash their hands in various contexts, including before and after meals, after using the restroom, following contact with animals or corpses, and after handling anything unclean.

In other cultures, hand hygiene practices emerged from scientific insights. In 1846, Hungarian physician Ignaz Semmelweis noted a higher maternal mortality rate associated with doctors who had previously handled cadavers. In response, he mandated handwashing with soap and chlorine for hospital staff, earning him the title of the father of hand hygiene. Shortly thereafter, visionary nurse Florence Nightingale implemented handwashing protocols in British military hospitals.

Despite these early efforts, regular handwashing was slow to gain traction globally. In the United States, national hand hygiene guidelines were not released until the 1980s, prompted by foodborne illnesses and hospital infections. It was during this decade that a global movement for hand hygiene emerged.

The introduction of hand sanitizers marked the transition of hand hygiene from medical settings to everyday life. Some sources attribute the invention of hand sanitizer to Lupe Hernandez, a nursing student in California, who in 1966 realized that combining alcohol with gel allowed for quick hand cleaning for hospital staff.

Others trace its origins to the Ohio-based company Gojo, which initially created a hand cleaner for auto mechanics and later modified the formula, releasing Purell in 1988. After a slow start, the product has become widely used.

Interestingly, alcohol-based sanitizers previously faced mixed feelings within Muslim communities due to the alcohol content being considered haram (forbidden). However, many Muslim healthcare professionals now accept them, although the debate over whether hand sanitizers are halal (permissible) continues.

Epidemics have consistently catalyzed the popularity of hand sanitizers. In the Philippines, a clothing retailer named Bench launched Alcogel shortly after the 1997 H1N1 outbreak, achieving remarkable success, as reported by the company's CEO Ben Chan. A similar trend was observed in the U.S. during the H1N1 pandemic of 2009.

As noted by The Guardian's Laura Barton in 2012, the heightened anxiety surrounding contamination during flu outbreaks has led to a societal value placed on carrying and using antibacterial gel.

Infectious disease outbreaks have also shaped handwashing habits. A study conducted in six international airports in 2003 revealed that 95% of male travelers and 97% of female travelers washed their hands in public restrooms in Toronto, which had experienced a severe acute respiratory syndrome (SARS) outbreak that year. In contrast, only 63% of men and 78% of women at New York's John F. Kennedy Airport did the same.

Is fear of disease a significant motivator for washing hands? Perhaps during a pandemic, the answer is affirmative. However, fear typically has a temporary influence on hygiene practices, according to anthropologist Valerie Curtis. Additionally, Curtis has cautioned that campaigns emphasizing cleanliness through fear are detrimental to mental well-being.

Instead, she advocates for leveraging a different emotion.

In the early 2000s, Curtis aimed to alter handwashing behaviors in Ghana, where merely 4% of adults routinely used soap after using the restroom. Previous initiatives had failed, and the urgency was heightened by an estimated 84,000 child fatalities from diarrhea each year.

Curtis devised a campaign to evoke disgust. At that time, bathrooms were perceived as cleaner than pit latrines, which did not inspire a sense of revulsion that could prompt Ghanaians to use soap. Her team created advertisements showing mothers and children emerging from restrooms with their hands stained in purple pigment, which they transferred to everything they touched. Following the campaign, soap usage increased by 13% after restroom visits and by 41% before meals.

Such an approach could inform future initiatives in the wake of COVID-19. A December 2019 study by researchers from the Massachusetts Institute of Technology (MIT) and the University of Cyprus estimated that if travelers improved their handwashing habits at airports, the impact of future pandemics could be reduced by 24% to 69%. However, despite 70% of air travelers reporting that they wash their hands, most do not do so adequately (frequently, with soap, for at least 20 seconds), resulting in only 20% having truly clean hands.

Pandemics tend to revert perspectives back to a Pasteurian view of germs.

Changing perceptions of microbes may complicate disgust-related issues. MIT anthropologist Heather Paxson argues that many individuals maintain a Pasteurian mindset, attributing colds to germs, demanding antibiotics, and consuming ultra-pasteurized products, while politicians apply hand sanitizer liberally on the campaign trail.

Yet Paxson also notes the emergence of an alternative paradigm: a "post-Pasteurian" perspective. Post-Pasteurians express concern about antibiotic resistance and embrace microbiome enhancers like probiotics, unpasteurized milk, kombucha, and unsanitized handshakes.

Since Paxson's findings were published in 2008, this post-Pasteurian viewpoint has gained traction. Scientists have explored methods to cultivate more positive sentiments towards microorganisms and foster cooperative relationships between humans and microbes.

Currently, the global atmosphere skews towards a Pasteurian perspective. People are inundated with images of a potentially lethal virus for which there is, at least for now, no vaccine or cure. Consequently, hand sanitizers and wipes boasting "kills 99.9 percent of germs" offer individuals a semblance of control over an invisible, and suddenly menacing, microbial environment.

However, the driving forces behind hand hygiene practices also include visible, often friendlier influences.

Research from 2016 indicated that healthcare professionals in a California hospital sanitized their hands 57% of the time when they were aware of being observed by designated "hygiene patrol" nurses, compared to just 22% when monitored by unrecognized volunteers.

Similar to the use of face masks, social pressure can effectively encourage hand hygiene. A recent review led by Curtis and other researchers revealed that individuals were more likely to wash their hands when accompanied by others in a public restroom.

In response to the COVID-19 pandemic, health experts are working to promote the idea that handwashing is a selfless act that saves lives. Social media initiatives like #SafeHands and #HandwashingHeroes appeal to social responsibility by featuring celebrities and children demonstrating handwashing to prevent disease.

Moreover, during the 1918 influenza pandemic, face masks became symbols of "public spiritedness." In certain countries, such as Japan, the habit of wearing masks persisted and became entrenched in the national hygiene culture.

Historically, after pandemics, individuals have generally reverted to previous handwashing routines. However, the COVID-19 pandemic is unique in that it has led to the global implementation of hand sanitizing and social distancing measures.

So, will COVID-19 result in lasting changes to global handwashing behaviors? Will hand sanitizer emerge as a lasting emblem of conscientious global citizenship? Will the pro-microbe stance revert to a Pasteurian anxiety about germs?

Only time will reveal the answers. But it's certainly a question to contemplate while you scrub or sanitize your hands for at least 20 seconds.

Gideon Lasco Senior Lecturer of Anthropology, University of the Philippines Originally published on SAPIENS on April 8, 2020.