key: cord-1001760-xtv5tlsw authors: Ray, Isha title: Viewpoint | Handwashing and COVID-19: Simple, right there…? date: 2020-07-14 journal: World Dev DOI: 10.1016/j.worlddev.2020.105086 sha: a4bb65860d3c8f27c991271491e49050f1ac1db0 doc_id: 1001760 cord_uid: xtv5tlsw COVID-19 is a disease with no proven pharmaceutical intervention and no proven vaccine. In such circumstances, prevention is all we have. The role of handwashing in the prevention of communicable diseases has been known for over a century, yet it remains severely neglected as a public health investment, to be periodically re-discovered during pandemic-scale infections. Over 26% of the global population has no access to a handwashing station in the home; for many low-income countries this proportion rises to over 50%. In other instances, the water is unaffordable or the supply has been shut off on account of unpaid bills. But when there is no water in the home or yard, or no mechanism for delivering enough water, good hand-washing is extremely difficult. Well before COVID-19, global cost-benefit analyses of water and sanitation investments, with benefits measured in time-savings as well as health, showed significant net benefits in all sub-regions of the developing world. This Viewpoint paper argues that, in the current crisis and its aftermath, it is imperative for governments and donors to prioritize and generously fund affordable, reliable, and accessible water services in underserved regions of the world. More than ever before, this is a foundational investment for health, dignity and development. COVID-19 is a disease with no proven pharmaceutical intervention and no proven vaccine. In such circumstances, prevention is all we have. The role of handwashing in the prevention of communicable diseases has been known for over a century, yet it remains severely neglected as a public health investment, to be periodically re-discovered during pandemic-scale infections. Over 26% of the global population has no access to a handwashing station in the home; for many low-income countries this proportion rises to over 50%. In other instances, the water is unaffordable or the supply has been shut off on account of unpaid bills. But when there is no water in the home or yard, or no mechanism for delivering enough water, good hand-washing is extremely difficult. Well before COVID-19, global cost-benefit analyses of water and sanitation investments, with benefits measured in time-savings as well as health, showed significant net benefits in all sub-regions of the developing world. This Viewpoint paper argues that, in the current crisis and its aftermath, it is imperative for governments and donors to prioritize and generously fund affordable, reliable, and accessible water services in underserved regions of the world. More than ever before, this is a foundational investment for health, dignity and development. Handwashing and COVID-19: Simple, right there…? As of July 4 2020, the official global death toll from COVID-19 had risen to 528,364. i Consider the 263 million people who have to fetch water that takes 30 minutes or longer to collect, or the 581 million that depend on unprotected wells, springs or lakes for their domestic needs (WHO/UNICEF 2017). Or consider the relatively fortunate households with piped water through taps shared with neighbors; certainly an improvement, but about a third of piped households in Africa and half in Asia, including those with private taps, receive only intermittently-supplied water (Kumpel and Nelson 2013) . Members of such households cannot soap up under running water every time they eat, come home with the groceries, clean their child's feces, or feed their animals. They must store water in metal and plastic containers between their walks to water, or between one supply cycle and the next. They have to pour or ladle water from the storage container into a bowl and then wash their hands with soap -ideally -in that bowl of standing water. If they have a designated handwashing station with e.g. a "tippytap", that is a significant improvement in access (Contzen et al 2015; Brauer et al 2020), but they are still washing hands in stored, and often standing, water. It is extremely difficult in these conditions to wash thoroughly, going between the fingers, scrubbing the thumbs, cleaning under the nails. It is impossible to wash the way handwashing is promoted in the media, with the hands lavishly lathered all the way to the wrists, next to a gushing faucet. Yet there is little public health guidance on how to wash "properly" with limited or stored water. If the water is not easily accessible, then the per-person use is usually inadequate for health and hygiene. If the home is small, the household is also storage constrained -so its members prioritize the limited stored water for drinking and cooking. A study from Mozambique found that a standpipe (public tap) 15 minutes away resulted in an average per-person per-day water use of 11 liters, but when the source needed a more than 2-hour roundtrip the daily use dropped to 4 liters per person; washing and hygiene practices accounted for most of the difference (Cairncross and Cliff 1987) . A study from East Africa found that significantly less water was used when the source was not on the premises; drinking and cooking uses were non-discretionary but unpiped households used only half as much water for hygiene as did piped households (Thompson et al 2001) . If there are overall water shortages, such as the shadow of Day Zero that loomed over Cape Town in 2018 and 2019, access for the poor becomes especially restricted. vi When I worked in rural India, I experienced this frugal approach to handwashing. The family I lived with had a communal tap and soap. But in the dry season, the between-supply spells could last for almost a week. By tacit agreement, we did not wash our hands with soap except after the toilet, because if we used soap, we would need even more water to get the soap suds off. Our carefully hoarded water had to stretch. (I got sick, of course). This is the lived reality of lowincome households in low-income countries -when there is no water in the home or yard, or no mechanism for delivering enough water, you cannot practice good hand-washing. COVID-19, we are told, cannot tell a celebrity from a commoner, a prince from a peasant. Piped water is far more discriminating. Even where there is a reliable water infrastructure, the water has to be affordable for frequent The biologist cited in The Guardian (see above) says that the message about handwashing is empowering because: "It's simple. It's right there and doesn't cost anything." For a sizable segment of the world, none of this is true. At this time, most WASH expenditures globally are borne by households, through user fees, tariffs and self-provisioning, especially where there are no utility-based services (Bartram and Cairncross 2010 ). Yet for many other preventive health measures, it is expected that states and donors will step in with subsidies, because of the externalities inherent in the containment of infectious diseases. The rolling back of state investments in backbone infrastructures, especially those for health and social protections, in high-and low-income countries alike has been "sharply regressive" (Marmot 2020 (Marmot : 1414 ). In the current crisis and its aftermath, it is imperative for governments and donors to generously fund affordable, reliable, and accessible water services in underserved regions of the world (including in the USA). Immediate measures, such as the provision of conveniently-located free-standing handwashing stations, should be prioritized for the poorest communities (see Biswas et al 2017). These investments will promote health, dignity and development. The demand-led employment they create could, with time, help revive the devastated global economy. Water for handwashing is a public good, and public goods call for public investments. 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