The key to beat superbugs? Handwashing

By Eric Stryson
The Straits Times

A new report in May has highlighted the growing threat of drug-resistant "superbugs". The projections of the Review on Antimicrobial Resistance (AMR) - prepared for the British government by economist Jim O'Neill - are disturbing: antibiotic-resistant bacteria already kill nearly a million people each year.

Worse, by 2050, this may rise to 10 million, potentially costing the world US$100 trillion (S$136 trillion) in lost productivity.

Society must focus on prevention and become much more prudent with the use of existing antibiotics in order to slow the emergence of drug-resistant bacteria. In South-east Asia, this means reducing usage by consumers, as well as by farmers who use antibiotics in agriculture. Prevention requires better sanitation and hygiene.

Across the region, access to sanitation remains problematic. The World Health Organisation estimates some 935 million people in South Asia and 176 million in South-east Asia lack sanitation. These areas will feel the impact of drug-resistant bacteria more acutely as infections become increasingly difficult to treat.

In South-east Asia, tuberculosis, gonorrhoea, cholera and pneumonia, among others, have already shown resistance to current drug treatments. The result is prolonged periods of sickness, more expensive treatments and greater risks to communities. Governments must prioritise the provision of water and sanitation systems to counter the spread of disease. In addition, the immediate and cost-effective way to reduce risk is handwashing with soap.

Handwashing does not solve the problem of drug-resistant bacteria. But it does slow the emergence of new resistance and saves people from getting sick with potentially untreatable illnesses. According to Unicef, the United Nations' children's agency, handwashing with soap after defecation and before handling food can reduce diarrhoea by up to 59 per cent, and respiratory illness by one quarter.

Handwashing can help eliminate millions of courses of antibiotics that are currently ineffectively and often inappropriately prescribed. Proper hygiene behaviour also helps prevent the spread of contagious diseases such as Sars, H5N1 influenza and Ebola, long considered impending threats among dense populations.

However, handwashing with soap is more commonly said than it is done. Notoriously difficult to monitor, rates of handwashing with soap vary dramatically, though rarely surpass 40 per cent to 50 per cent at key times and can be much lower, according to international studies. Even among medical professionals, there is an overall median compliance rate of only 40 per cent, according to the AMR global report.

Knowledge and practice are not equivalent. Establishing regular hygiene behaviour requires water, soap and a convenient basin together at the proper time and place - an "enabling environment".

For those living in affluent cities, this challenge may not be obvious. Yet, piped water and modern sinks are expensive and often unavailable in rural areas. Traditional water storage methods create awkward logistics for handwashing.

Makeshift solutions often involving recycled plastic bottles or milk cartons attached to a tree or post can be free, but have proven unsuccessful in changing behaviour. Because they are free, such devices are not valued and easily discarded. As one development expert said: "People don't want to use something that looks like rubbish hanging in their yard." Undeniably, the goal is regular usage.

In response, a small company in Vietnam has launched an innovative and attractive low-cost consumer product that promotes behaviour change, born from the Global Scaling Up of Handwashing campaign, a project under the water and sanitation programme that is part of the World Bank Group's Water Global Practice.

Our think-tank, the Global Institute For Tomorrow (Gift), supported this process. Currently wholly-owned by the WaterSHED non-governmental organisation, the social-business is now seeking to scale up production and distribution throughout the region.

Designed through a human-centred design process, it was a finalist for the World Design Impact Prize, which encourages industrial design driven projects that benefit society. Imagine a "portable sink" complete with soap tray, wastewater pipe and modern design, placed in the kitchen or outside the latrine, with optional mirror, dental kit and make-up - an aspirational, modern lifestyle product, yet still affordable at about US$12.

This contrasts with products in other regions that retail for US$200 or public hand sanitiser devices which require regular servicing.

The number of rural residents in Asean who could stand to benefit from a low-cost product that changes handwashing behaviour could amount to well over half of the region's 625 million population.

Countries with the greatest need for such a handwashing device, based on the percentage of the population with what is termed "improved sanitation", according to World Bank figures, are: Cambodia, 42 per cent (which means 58 per cent do not have access); Indonesia, 61 per cent; Laos, 71 per cent; the Philippines, 74 per cent; Vietnam, 78 per cent; and Myanmar, 80 per cent.

However, even where there is improved sanitation, there may not be running water, and in many rural areas there is no piped water into the household, so it is inconvenient to wash one's hands with soap.

Handwashing is the most important preventative measure that can be implemented today. Other more costly and time-consuming investments in infrastructure and new pharmaceutical cures are also necessary. Singapore and other centres of innovation should incentivise the development of new drugs. Concurrently, Asean should set targets to reduce overall antibiotics usage.

Doctors, meanwhile, must be more conservative with prescriptions and also seek to facilitate handwashing behaviour among patients.

Everyone will have a role to play in this critical race against drug resistance - and it starts with prevention.