All Hands on Deck for a Handwashing Indicator

This is a joint post with Rachel Silverman. 

Break out the firecrackers and balloons – and water and soap: today is Global Handwashing Day! And while today's significance may get lost in the very busy calendar of Global Health "holidays", this one really does deserve special celebration. Decades of public health research show that the simple act of regular handwashing can save hundreds of thousands of lives, if not up to a million lives. My own research in India found that handwashing is an extremely powerful means to prevent child diarrhea, the world’s second leading cause of death among children under age five.

The UN and UNICEF have joined the handwashing party, at least rhetorically. Their annual reminder to encourage handwashing is a nice, if perhaps somewhat perfunctory, gesture of concern. Still, handwashing remains neglected among global health priorities, and has long laid in the shadows of its more prominent siblings – water and sanitation. Whereas water and sanitation were included within the Millennium Development Goals, handwashing didn’t make the cut, even though handwashing with soap is more effective (48%) on average in averting diarrheal deaths than improving water quality (17%) -- though potentially less effective than building toilets (69%). And while there are many estimates for important health-related activities, including access to improved water and sanitation sources, little data exists on global hand washing prevalence (which is why in this valuable PLOS Medicine paper on scaling up diarrhea prevention the authors were forced to make heroic guesses of handwashing prevalence despite handwashing’s importance).

In fact, the de facto data sources for health status indicators -- USAID’s Demographic and Health Survey (DHS) and UNICEF’s Multiple Indicator Cluster Surveys (MICS) --  frequently measure all kinds of personal information (e.g. one’s preferred method of contraception), but handwashing is perennially omitted, even though it is crucial for preventing both diarrhea and respiratory infections among children and adults. And in my forthcoming paper (an extension of a previous blog post), coauthored with Rachel Silverman, Alex Rosisinki, and Jesse Bump, we find that while the total number of World Health Statistics indicators have increased over an 8-year period, the number of indicators actually decreased for water, sanitation, and hygiene.

We all know that “what gets measured gets done”, meaning that indicator selection and data collection matter a great deal in setting and achieving global health priorities.  So we ask USAID and DHS: how does an indicator make its way onto the standardized questionnaire for DHS or MICS, and why has hand-washing failed to make the jump? Is it an absence of vocal advocates? I would urge child survival advocates to raise the priority of handwashing among donor and survey operators. With a staggering 2 million preventable deaths each year from diarrhea and respiratory infections worldwide, today's occasion would be the perfect time for the global health community to spring for a shiny new handwashing indicator.