October 4, 2018
Written by Sian White, London School of Hygiene and Tropical Medicine
It’s an early morning in the Hitsats refugee camp in northern Ethiopia. A group of eight young Eritrean men are preparing to start the day. A few months ago these men didn’t know each other – now they share a shelter and two cramped beds. Their shelter is not what you might expect from a ‘bachelor pad’ in a refugee camp. Hygiene seems to be of utmost importance to these men and everything is neat and in its place. Despite being thrown together like this, the men seem to have developed their own role within this new ‘family unit’.
When each of the men woke up, they washed their hands, face and feet – some with just water, some with water and soap. Now, as they begin to cook breakfast, things get a bit more complex. One person is dicing the onion. He didn’t wash his hands before doing so. Another chops a tomato – he managed to rinse his hands and the tomato at the same time. Two men fuss over the charcoal burner, trying to get it lit, eventually borrowing some hot coals from the neighbour. Their hands are visibly dirty afterwards, so they go outside to both rinse their hands – pouring water for each other to do so.
Outside, the dishes and utensils are being washed by another man; he manages to give his hands a good rinse and lather with soap in the process. One man goes to the makeshift storage room next door and fills a jug with water, intentionally tipping a little on his hands in the process. Another man returns from the shop, holding freshly baked bread in his unwashed hands. The man chopping the onion comes over, ripping the bread with his still unwashed hands. Meanwhile, the last man of the bunch sits down by the charcoal burner, fans the fire, and starts cooking the onion, tomato, and spices. He did not wash his hands before jumping into the role of chef. Adding the jug of water to the mix slowly, he pours the mixture onto the bread and mixes it around by hand.
Throughout this food preparation process, the men have chopped firewood, used the toilet, washed laundry, styled their hair, greeted neighbours, and spent time playing on their phones. Eventually though, the men gather around and eat from a communal plate – some using their hands, some using spoons – but all laughing and joking because after all, shiro and bread is the household favourite.
The challenges these men face are not unique. I have seen similar patterns of behaviour play out in camps and communities in all parts of the globe – from Nigeria to Indonesia and Iraq. Within the water, sanitation and hygiene (WASH) sector, we often talk about critical moments for handwashing with soap. One of these critical moments is before preparing food. However, defining ‘a moment’ prior to food preparation may be a fallacy – incongruous with the realities of the task. Food preparation is rarely a straightforward continuous process that is performed by just one person.
Think about your own cooking. How often have you had to take a phone call while cooking? Attend to a crying child while cooking? How often have you had to wait for your dish to cook and in the meantime, you’ve chosen to occupy yourself with a range of other household tasks? In the process of food preparation (and due to interruptions commonly experienced during the food preparation process), we frequently re-contaminate our hands. In many high income settings where we have ‘designed-out’ a lot of our environmental risks, this may not be a major issue. But in low and middle income contexts, or in refugee camps like Hitsats, this re-contamination poses a genuine diarrhoeal disease risk. If the men in the scenario above were to have strictly adhered to the WASH sector’s advice, then collectively they would have had to wash their hands with soap more than 30 times! Obviously, this is an impractical amount of time and effort. In a context like Hitsats where water and soap are limited, it also would simply not be possible.
In Hitsats camp, there have been trials on a new hand cleaning product that might be able to reduce re-contamination during the food preparation process. The product is called the SuperTowel. At first glance, the towel looks much like a standard microfiber dishcloth. But when dipped into water, its superpower is activated! The SuperTowel fabric is treated with a permanent anti-microbial bonding. When the damp towel is rubbed against the hands, pathogens are transferred to the fabric where they are killed. The anti-microbial technology does not involve toxic chemicals. Instead, it is achieved by long chains of carbon atoms attached to positively charged nitrogen atoms bonded to a silica layer of the fabric. The positively charged layer attracts negatively charged microbes (including bacteria, protozoa, fungi and encapsulated viruses) causing membrane disruption of the microbes. Earlier this year, we conducted laboratory tests on the SuperTowel and found that under controlled conditions it was more efficacious than handwashing with soap. Even with this success in the lab, we weren’t sure whether the SuperTowel would be an acceptable or practical product for humanitarian crises or other settings where handwashing with soap is challenging.
We ran behaviour trials with a select group of households in Hitsats camp, providing each family member with a SuperTowel and then getting them to use it for a period of 13 days. In general, we found that participants really liked cleaning their hands with the SuperTowel. Participants explained that one of the key differences was that the towel allowed them to easily clean their hands at times when they might normally not bother to wash their hands with soap. Many of the ‘minor moments’ of hand contamination that they described happened during food preparation.
When we returned to the men’s house at the end of the behaviour trial, we found each of them actively using the SuperTowel – all except one that is. One SuperTowel had been put aside for a special purpose. The men had come to an agreement that they would share the use of seven of the SuperTowels and that the remaining SuperTowel should be kept on a hook near the cooking place. The men explained that this meant it was always easy for them to clean their hands at multiple times during food preparation.
The SuperTowel product was developed by RealRelief with funds from the Humanitarian Innovation Fund. It is being tested with support from the London School of Hygiene and Tropical Medicine and the Danish Refugee Council.