Why Singing "Happy Birthday" Twice Can Save Millions of Lives

In the middle of the 19th century, the General Hospital in Vienna had two maternity clinics with very different outcomes in terms of mortality: twice the number of women died of puerperal fever in one clinic as compared to the other (16% versus 7%). Ignaz Semmelweis, a young Hungarian doctor, soon realized that the only difference between both clinics was that, in the first, women were attended to by medical students who also performed autopsies, while in the second clinic they were attended to by midwives.

Semmelweis concluded that the doctors transported “cadaverous particles” on their hands from the autopsy room to the delivery room (remember that Pasteur and his ‘germ theory of disease’ arrived a few years later). Thus, he made students and doctors wash and scrub their hands in a chlorinated solution after leaving the autopsy room and before touching their patients. The result was almost miraculous: maternal mortality in the first clinic fell below 3%.

This experiment, performed in 1847, provided the first evidence that washing hands prevented infections. However, the innovation was not popular among the Hungarian doctor’s colleagues, who felt they were being blamed for the deaths. They soon stopped washing their hands and they fired Semmelweis, who began writing angry letters to his ex-colleagues, calling them murderers. In 1865, he was committed to an asylum, where ironically he died of septicaemia a few days later as the result of a severe beating by the guards.  

Body soap has existed since ancient times, but the link between hand hygiene and disease spreading was established less than 200 years ago

A few years after Semmelweis’s experiment, the Crimean War (1853-1856) brought another hand hygiene champion: Florence Nightingale. The British nurse travelled with 38 volunteers to the military hospital in Scutari, Istambul, where many more soldiers were dying from diseases such as typhus and cholera than from battle wounds. The hand washing and hygiene measures implemented by Nightingale – together with her great working and organization capacities- achieved remarkable reductions in the number of infections, which earned her the Order of Merit in 1907.

The practices promoted by Semmelweis and Nightingale became more widely accepted thanks to the work by Pasteur, who demonstrated that microorganisms are the cause of infectious diseases, and by Lister (known as the father of modern surgery), who introduced the practice of sterilising material and wounds, in addition to hand washing, when practicing surgery.

The so-called Semmelweis reflex, in honor of the Hungarian doctor, designates the human reflex of rejecting all new knowledge because it contradicts entrenched norms, beliefs or paradigms

Even then, it wasn’t until midlle of the 20th century that for example the US Center for Disease Control and Prevention (CDC) identified hand hygiene as an important measure to prevent the spread of infection. The first national hand hygiene guidelines were published in the 1980s by the US and other countries.   

World Hand Hygiene Day, whose theme this year is “Clean care for all- it’s in your hands”, is the perfect occasion to share once again basic advice on how to clean hands and protect against infection, addressed particularly, but not exclusively, to health care workers.

Washing one’s hands properly, as illustrated in the images, takes about 30 seconds. If you prefer singing to counting, it should take as long as singing "Happy Birthday" twice!

How Do I Wash My Hands Properly?

Washing your hands properly takes about as long as singing "Happy Birthday" twice, using the images above. Source: World Health Organization (WHO).

Today, hand washing with soap and/or alcohol-based solutions is recognised as one of the best and most cost-effective measures to improve health and prevent infections, particularly in hospital settings. In fact, the World Health Organisation (WHO) considers hand hygiene a key element to achieve universal health coverage, due to its enormous impact on care quality and patient security across all health system levels. One in every 10 patients contracts an avoidable infection when receiving health care, according to WHO estimates.    

Now that the effectiveness of hand hygiene is beyond question, the challenge lies in making handwashing universal. In the 21st century, one in four health care facilities worldwide still lacks basic water services, according to a recently published report by UNICEF and WHO. This means that almost 2 billion people attend health facilities that lack basic water and sanitation services and that 17 million babies are delivered in such conditions, which poses a great risk of infection for the mother and the newborn. An estimated one million deaths occur each year due to “unclean” births, which are not due to a lack of will from health care professionals, as occurred in Semmelweis’s epoch, but to a lack of infrastructure and resources.

Photo: Pablo Tosco/Oxfam

The WHO-UNICEF “Practical Steps” report identifies eight actions governments can take to improve water, sanitation and hygiene (WASH) services in healthcare facilities. These often-simple actions can yield remarkable returns of investment in terms of improving maternal and newborn health, preventing antimicrobial resistance, stopping infectious disease outbreaks, and improving quality of care.

For our part, each time we wash our hands (the more, the better), we can think of the sad fate of Semmelweis, born 201 years ago and ahead of his time, while we sing him “Happy Birthday” – twice.