The time is now to replace outdated and dangerouss hospitals…


The physical design and infrastructure of a hospital or institution is an essential component of its infection control measure. Thus is must be a prerequisite to take these into consideration from the initial conception and planning stages of the building. The balance between designing a hospital to be an open, accessible and public place and the control to reduce the spread of infections diseases is a necessity. At Singapore General Hospital, many lessons were learnt during the SARS outbreak pertaining to this. During and subsequent to the SARS outbreak, many changes evolved in the hospital to enable us to handle and face any emerging infectious situation with calm, confidence and the knowledge that staff and patients will be in good stead.

This paper will share some of our experiences as well as challenges

Keywords: Emerging infection, infection control measures


When the statutes of the hospital of St John Bridgewater were developed in 1219, Bishop Joscelin of Bath commented -, “No lepers, lunatics or persons having the following sickness or other contagious diseases are to be admitted to the house, and if any such be admitted by mistake, they are to be expelled as soon as possible”.[1] Hospitals and healthcare institutions have certainly come a long way from the days of Bishop Joscelin. We are not as drastic in our sentiments today and we do not expel patients with infectious diseases. In fact, we admit them to suitably planned facilities and rooms and ensure that they do not cause unnecessary hazards to staff and other hospital users.

The physical design of a hospital is an essential component of its infection control measures to minimize the risk of transmission of any infectious disease. When historical and traditional hospitals were built, there were minimal concerns of new emerging infectious diseases. Today, with a more progressive outlook, it is the fundamental requirement to adopt a holistic view of the design and management of hospitals. Designing hospitals to be open, public spaces can make it difficult to control the spread of infectious diseases. The ease of travel and transportation today helps people cross borders easily. They can harbor, carry or catch infectious agents readily. During the Severe Acute Respiratory Syndrome (SARS) outbreak it became clear that the multiple public entrances in hospitals make it difficult, and often costly, to control entry and thus infiltration of infectious diseases.[2,3]

Only a few hospitals have an adequate supply of isolation and negative pressure rooms in wards, emergency departments (EDs) and Intensive Care Units (ICUs). While hospitals may not have complete control over host factors and agents, they are still responsible for the environment that surrounds the patients. By controlling and ensuring adequate sanitization of the environment of the host, hospital authorities can reduce the incidence of hospital acquired infections.

A decision on hospital buildings must be based on multiple factors besides cost, like fire protection, strength of construction material, hygiene, building health, environmental protection, sound isolation, energy saving, durability and utilization rate, among others. Even after initial completion of the hospital building, systematic data collection and feedback for addition, modification and upgrading of the infrastructure must be ongoing.[4] Built-in flexibility in design is becoming more crucial, mainly because technology is quickly obsolete and patient population is constantly changing. For example, single rooms may be more useful to have as they can be converted to isolation rooms more readily during an outbreak. Healthcare buildings are a complex environment with a need for specialized areas like high wear and tear areas, circulation areas, wards, specialized theatres and hazardous material chain of disposition. Choice of material and finish is also important and needs to be mainstreamed into the planning stages.[2,4]

With the challenges of new and emerging infectious diseases as well as higher public expectations and awareness of healthcare related issues, much consideration has to be given to these in the planning phase of building hospitals. For existing institutions and hospital buildings, renovation and upgrading plans must incorporate the necessary changes. Among the various methods for infection control two important environment factors are isolation and ventilation. Infected patients or those highly susceptible to infection need to be isolated in private rooms with proper ventilation systems in order to stop spread and reduce the possibility of developing a new infection. Bronson Methodist Hospital in Michigan demonstrated that private rooms, location of sinks and air flow design have resulted in a 10-11% decline in overall nosocomial infections rate.[5]


Following the experience of SARS in 2003, infectious diseases and potential infectious patients are now being managed with high vigilance in an upgraded infrastructure at Singapore General Hospital. At points of entry into the hospital and in the ED, patients are screened using a rapid questionnaire on their travel exposure, fever history and symptoms. Body temperature is recorded and documented. Any one with fever and a positive response to any question will be channeled to be managed in the febrile area of the ED. This febrile screening step is done outside the ED in a specially planned area before formal ED triage is done. The rationale is to identify the high risk patients as soon and as early as possible. Other points of entry into the hospital are also regulated, especially during high risk periods.

Patient management in fever area

These areas are relatively new areas, constructed following the lessons learnt during the SARS outbreak [Figures 1and and2].2]. Many healthcare systems were overwhelmed by the SARS epidemic. The system design, public health functions, equipment and supplies as well as collaborative arrangements were either not in place or not in alignment then. Existing triage areas in the ED are often designed with patient flow and satisfaction in mind, rather than healthcare workers safety and protection. As air currents may transport infections, fever and high risk patients are now being managed separately from others. The febrile areas in the ED have undergone structural re-engineering and upgrading of the ventilation system [Figure 3]. There usually exist design flaws in many hospitals, such as turbulent ventilation across patient access areas, the flow of aerosolized gases between treatment areas and the shortage or absence of negative pressure rooms. Consideration of design, equipment and ventilation are important Building ventilation, whether natural or mechanical serves to dilute droplets nuclei in the air and is the single most important engineering control in the prevention of transmission of airborne infections.[68] In the new fever areas, rooms with negative pressure ventilation are now available. The exhaust rate in these rooms must exceed the air supply rate by a generous margin. Infected air from patients in this area is prevented from staying in the area and circulating in the corridor, by an exhaust system that filters it to the outside environment. During the construction phase, it is essential to consult the ventilation engineer with regard to the sufficient amount of flow without causing too high turbulence.

Figure 1

The separate screening area for febrile patients
Figure 2

A separate new entrance to the ‘fever area’ where there is minimal air mix with the other areas of the emergency department
Figure 3

“Fever” consultation rooms with negative pressure ventilation

The positive pressure gradient between the isolation cubicles/rooms and the rest of the area is approximately 15 Pa. A negative pressure room should also preferably have windows which do not open. Having ante-rooms too will help reduce the escape of droplet nuclei during opening and closing of doors. It must also be noted that patients and staff in negative pressure rooms are at increased risk in the event of a fire. This is because fire and smoke can be drawn into these rooms from the adjacent corridors or wards by reason of the differential pressures. The SARS virus is transmitted primarily by bio-aerosol droplets or direct, very close personal contact. During the outbreak when onsite measurement of bio-aerosol dispersion was done, it was able to predict the distribution fairly well, in agreement with the spatial infection pattern of SARS cases.[3]

Febrile patients who are non-ambulatory and too ill to walk are managed in the critical care/resuscitation area which has two end rooms prepared with negative pressure ventilation and separated from other cubicles with heavy lead doors [Figure 4].

Figure 4

Negative pressure ventilation end cubicle in the resuscitation area with lead X-ray proof door partitions

The observation unit in the ED is also equipped with isolation rooms for the management of potentially high risk and infectious patients. The doors of these rooms are fitted with a self closing device. For isolation rooms with no negative pressure ventilation, it is important to have them well ventilated with adequate fresh air exchange. The hospital Infectious Diseases committee has also come up with guidelines and operating procedures on the recommendations for the admission of suitable patients to isolation rooms as well as negative pressure rooms.

These infrastructure changes and facilities are not going to be effective if the staff do no change their mindset and remain highly compliant with guidelines and safe practices [Figures 5 and and6].6]. A consolidated strategy which is multipronged is essential. These would include not just structural changes but also mechanisms for contact tracing, syndromic surveillance, proper hand washing techniques and the practice of universal precautions.

Figure 5

A separate emergency pharmacy in the ‘fever’ area to reduce patient movement as much as possible
Figure 6

Signages and restricted entry points are important especially during outbreaks

Disinfection and cleaning of the febrile areas too represent a crucial duty. Non-disposable material, equipment and work surfaces must be subjected to frequent cleaning and thus must incorporate materials with resistance to solutions and solvents as well as spread of infection. Disinfection with hypochlorite, 1000 ppm, is regularly done. This is for all wards, environment, facilities, equipment, horizontal surfaces, surfaces touched by patients and staff as well as toilet facilities. Other considerations include humidity control which can have an effect on the spread of infection such as methicillin resistant Staphylococcus aureus (MRSA). In fact the choice of color and ambience of the hospital areas and rooms can have an effect and psychological implications on both staff and patients treatment, management and[911] recovery.


The experience of controlling SARS provided many lessons on how to prepare for a major outbreak. Improving general infection control measures and procedures as well as preparedness has the potential to enhance routine healthcare on a daily basis as well as increase our chance of a successful handling of the next pandemic.

One key component of limiting the spread of healthcare related infectious diseases is adequate infection control practice. A cornerstone of this is ensuring good hand hygiene. Hand washing has been recommended as the single most important practice to control hospital acquired infection. In isolation rooms, of observation and general wards, there are personalized hand washing facilities within each room to reduce cross-contamination. These isolation rooms help to prevent direct and even indirect contact transmission and droplet transmission. Access to examination gloves, alcohol-based hand-rub and trash containers or receptacle is also important. Many have the perception that unavailability or inadequate hand washing facilities and sinks contribute towards poor compliance. Few studies have prospectively evaluated the association between hand hygiene compliance and building plan and design. Lankford et al. found that hand hygiene compliance in a new healthcare facility (with more sinks provided) decreased significantly.[12] They concluded that peer and team behaviour have greater impact on good habits rather than just building design and ergonomics. This was echoed by a few other studies as well.[13,14]


In performing procedures where there exists a considerable and high risk of transmission, appropriate garment and devices have to be used. These would include, N 95 masks, goggles and face shields, hair and shoe covers, impervious gowns and aprons as well as positive pressure air-powered respirator (PAPR). The latter is a hood worn over the head and face to shield the healthcare personnel from air droplets and any secretions from infected patients when performing procedures such as suctioning and endotracheal intubation.


In handling an outbreak such as SARS there must be good coordination at all levels. This would mean the communications must be excellent as well. Relevant messages, information and instructions must be disseminated effectively through an agreed upon channel or system. Notification of infectious disease cases must also be timely and this calls for staff to be highly vigilant.

At Singapore General Hospital, with the use of computerized records, it is easier to trace and track patients and information. This is important for contact tracing and syndromic surveillance. In the re-engineering of the departments, after SARS, inputs from clinicians and nurses were obtained. Infectious diseases specialists also played an important role from the inception, where they educated the engineers and architects as well as the contractors about potential infection control risks. Frequent site visits are a must. Caution must also be maintained when interpreting results from infection control literature, because the findings and recommendations are often based on retrospective investigations of infection outbreaks in particular settings and thus are tailored to those settings. They may or may not be applicable to other settings.[15,16]


In being able to handle outbreaks well, there must be collaboration and a consolidated strategy which is understood and practiced by all. At the hospitals there must be continuity between Emergency Departments, observation wards and general wards, ICUs, isolation wards, operating theatres, laboratories and outpatient clinics. However, this must go beyond just healthcare institutions and hospitals. At the national level, it must include primary care and general practice clinics, communicable diseases centers, government services, schools, the mass media and press, immigrations department, transportation department, pharmaceutical industry, the police and many more. Frequent exercises to practice and test out our preparedness are also very crucial because then only can we learn the setbacks and correct them.

The Ministry of Health, Singapore Medical Association, College of Family Practitioners and various other healthcare organizations have created a detailed plan called the Primary Care Pandemic Framework, to help primary care clinics work with the 18 government polyclinics to provide appropriate care for influenza and non-influenza patients during a pandemic. The Framework advises on how to prepare and organize a primary care clinic for a pandemic; including modifications to clinic workflow and processes to avoid cross infection, use of personal protection equipment, hospital referral and environmental design and cleaning.[17] Both infrastructure and design have a significant effect on our work in the healthcare sectors. This issue has often been taken for granted but now is the time to make it work for us and our patients.


Source of Support: Nil.

Conflict of Interest: None declared.


1. Maxwell-Lyte HC, editor. The refute of Thomas Beleynton, Bishop of Bath and Wells. Somerset, UK: Somerset Recard Society; 1934. pp. 1443–65.pp. 289
2. Cameron PA, Schull M, Cooke M. The impending influenza pandemic. Lessons from SARS for hospital practice. Med J Australia (eMJA) 2006;185:189–90. [PubMed]
3. Li Y, Huang X, Yu IT, Wong TW, Qian H. Role of air distribution in SARS transmission during the largest nosocomial outbreak in Hong Kong. Indoor Air. 2004;15:83–95. [PubMed]
4. Bogenstatter U. Prediction and optimization of life cycle essential in early design. Building Research and Information. 2000;28:376–86.
5. The cost of nosocomial infections. The Centre for health Design: News Brief. 2003. Nov 18, Available from:Http:// [last accessed on 2008 Oct 20]
6. Baker J, lamb CW., Jr Physical environment as a hospital marketing tool. J Hospital marketing. 1992;6:25–35.[PubMed]
7. Burmahl B. Facilities of the future: New design puts patients first. Health Facilities Management. 2000;13:30–4.[PubMed]
8. Coile R. healing environment: Progress towards evidence-based design. Russ Coile Health Trends. 2001;13:8–12.
9. Cys J. want healthy patients? Ambience may be the answer. AHA News. 1999;35:9.
10. Gallant D, lanning K. Streamlining patient care processes through flexible room and equipment design. Critical care nurs Quarterly. 2001;24:59–76. [PubMed]
11. Horsburgh RC., Jr Healing by design. NEJM. 1995;333:735–40. [PubMed]
12. Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on hand hygiene of health care workers. Emerg Infect Dis. 2003;9:217–23. [PMC free article][PubMed]
13. Harvey MA. Critical care unit bedside design and furnishings: Impact on nosocomial infections. Infect Control Hosp Epidemiol. 1998;19:597–601. [PubMed]
14. Feather A, Stone SP, Wessier A, Boursicot KA, Pratt C. “Now please wash your hands” The handwashing behaviour of final year nurses candidates. J Hosp Infect. 2000;45:62–4. [PubMed]
15. Lawson B, Phin M. hospital design: Room for improvement. Health Sciences J. 2000;110:24–6. [PubMed]
16. Spear M. Current issues: Designing the universal patient care room. J Healthcare Design. 1997;9:81–3.[PubMed]
17. A guide to organizing a primary care clinic during an influenza pandemic Version 1. 2007. Jul, Available from:Http:// [last assessed on 2008 Sept 1]

Articles from Journal of Emergencies, Trauma, and Shock are provided here courtesy of Medknow Publications


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Hospital infection is the next asbestos

Until recently, infection was considered the inevitable risk you faced if you were hospitalized. That is changing. Now there is compelling evidence that nearly all hospital infections are preventable when doctors and staff clean their hands and adhere to other low–cost infection prevention measures. These findings put hospitals in a new legal situation. The assumption that infections are unavoidable shielded hospitals from liability for decades. But not in the future. Hospital infections could be the next asbestos.

The Society for Healthcare Epidemiology of America and the Committee to Reduce Infection Deaths (RID) have urged hospitals everywhere to implement the precautions that have nearly eradicated drug–resistant infections in Holland, Finland, Denmark, and in the few hospitals in the U.S. Hospitals that continue to ignore this call will face embarrassing public comparisons and numerous lawsuits as well.

Most victims who sue will not be able to prove precisely how the bacteria entered their body while they were hospitalized. Soon, it may not matter.

Jurors will be told that the hospital failed to enforce hand hygiene rules and implement necessary infection prevention practices and, consequently, should be deemed negligent and held liable, even strictly liable in some cases, for patients’ infections.

Many questions will be raised by these lawsuits. According to the CDC, at least half of hospital infections could be prevented if caregivers clean their hands immediately before touching patients. Most hospitals tell doctors and nurses to clean their hands, yet doctors break this fundamental rule 52% of the time, on average. When hand hygiene rules are not enforced, infections are foreseeable. A few hospitals are devising sanctions, such as suspending admitting privileges or curtailing operating room time to discipline chronic offenders. Will hospitals that fail to do this be deemed negligent and held liable for the infections their patients contract?

Astoundingly, most U.S. hospitals don’t routinely test incoming patients for MRSA. Seventy to ninety percent of patients carrying MRSA are never identified. Knowing which patients are sources of infection is key to stopping the spread. If you’re placed in a semi–private room with a patient carrying MRSA, you’re at increased risk of infection. Also, as a new study in Infection Control and Hospital Epidemiology documents, if you’re placed in a room previously occupied by a patient with MRSA, your risk of infection increases, because the bacteria linger on floors and furniture long after the patient carrying these bacteria is discharged. Will hospitals that fail to test incoming patients and isolate those testing positive be deemed negligent and held liable when a patient contracts a deadly MRSA infection?

Surgery patients can reduce their risk of infection by bathing or showering with chlorhexidine soap daily before their operation. Will a hospital that fails to advise patients to take this precaution be deemed negligent and held liable when a patient develops a surgical site infection?

Will a hospital be deemed negligent and held liable if the staff forgets to administer a prophylactic antibiotic within an hour of the incision, the standard of care in most cases, and the patient subsequently contracts a surgical site infection? What if the staff shaves a patient before surgery, contrary to best practices, and the patient comes down with an infection?

Even where there is no evidence that a hospital overlooked infection prevention measures, the plaintiff’s attorney could argue that infection is evidence enough that the hospital breached its duty. Every law student learns about the barrel that fell out of a merchant’s second story window, injuring a customer below. The merchant is held liable because the accident was itself definitive evidence of negligence, a textbook example of res ipsa loquitur. Similarly, trial lawyers will claim that an infection speaks for itself,” and shifts the burden onto the hospital to offer evidence that it was not negligent.

Res ipsa loquitur already has played a prominent role in medical malpractice cases in New York state and elsewhere. What will be new is its applicability to hospital infection. For example, in 1997, the New York State Court of Appeals granted a new trial for a plaintiff who had undergone a hysterectomy and subsequently found an 18″ by 18″ laparotomy pad left in her abdomen. The Court of Appeals ruled that the jury should have been told that the error speaks for itself: once the plaintiff proves that “the event was of the kind that ordinarily does not occur in the absence of someone’s negligence, that it was caused by an agency or instrumentality within the exclusive control of the defendant, and that it was not due to any voluntary action or contribution on the part of the plaintiff, a prima facie case of negligence exists.”

The Court of Appeals also explained—and this is key to future litigation based on infection—that “to rely on res ipsa loquitur a plaintiff need not conclusively eliminate the possibility of all other causes of injury. It is enough that it is more likely than not that the injury was caused by the defendant’s negligence.”

A rapidly growing body of new evidence shows that almost all hospital infections are preventable if hospital staff are trained in the correct procedures and required to follow them. Had the plaintiff in Hoffman v. Pelletier et al (6 A.D. 889, 775 N.Y.S. 2d. 397, 2004 N.Y. App. Div) presented such evidence, the trial court probably would not have granted summary judgment for the defendants. The plaintiff had developed a Staph infection following cervical surgery, and sued her surgeon and the hospital. The trial court granted summary judgment for the defendants. “Since plaintiff offered no proof that such infections do not occur in absence of negligence, res ipsa loquitur was inapplicable,” reasoned the court. Though such evidence was already available in 2004, it is far more plentiful and well documented in medical journals now.

What must hospitals do to avoid liability for infections? That’s still unknown. Courts will decide, “probably moving from common law negligence to the eventual establishment of strict liability,” according to Sanford Young, Esq., a New York lawyer. In the early cases, plaintiffs may have to point to specific departures from best infection prevention practices, such as shaving patients before surgery, to prevail. Exactly how the legal precedents will develop is unknown.

Lawsuits are not the best way to improve patient care. They often result in unfair verdicts, and few truly injured patients have access to legal remedies (as few as 2%, according to the Harvard Medical Practice Study). Nevertheless, hospitals that act decisively will have the best insurance against costly damage awards: clean, safe care.


The Semmelweis reflex or “Semmelweis effect” is a metaphor for the reflex-like tendency to reject new evidence or new knowledge because it contradicts established norms, beliefs or paradigms.


The term originated from the story of Ignaz Semmelweis, who discovered that childbed fever mortality rates reduced ten-fold when doctors washed their hands with a chlorine solution between patients and, most particularly, after an autopsy (at the institution where Semmelweis worked, a university hospital, physicians performed autopsies on every deceased patient). Semmelweis’s decision stopped the ongoing contamination of patients—mostly pregnant women—with “cadaverous particles”.[1] His hand-washing suggestions were rejected by his contemporaries, often for non-medical reasons. For instance, some doctors refused to believe that a gentleman’s hands could transmit disease (see Contemporary reaction to Ignaz Semmelweis).

While there is some uncertainty regarding the origin and generally accepted use of the expression, the expression Semmelweis Reflex has been documented and at least used by the author Robert Anton Wilson.[2] In Wilson’s book The Game of Life, Timothy Leary provided the following polemical definition of the Semmelweis reflex: “Mob behavior found among primates and larval hominids on undeveloped planets, in which a discovery of important scientific fact is punished”.

It’s time to separate Medicine and the Drug Industry

Correction Appended

It was in 1949 that Elvin Stakman, president of the American Association for the Advancement of Science, issued the membership their marching orders: “Science cannot stop while ethics catches up.”

And sure enough, from bombs to clones, the ethicists have generally kept to the rear of the scientific parade: they are the ones with the big brooms trying to restore order after the floats and the elephants go by.

Those brooms sweep slowly. Often, by the time the ethicists finish laying out facts and weighing relevant moral values, the worst of any given crisis has passed. But recently, those who work in medicine have moved closer to the fray: they staff acute-care hospitals and monitor events in real time, aiming for a little less retrospective philosophy and a little more damage control.

In this proactive spirit Howard Brody, a medical ethicist, has brought his discipline’s tools to the relationship between the medical profession and the pharmaceutical industry. This problematic tangle of moral compromise (or triumphant health-promoting collaboration, depending on your point of view) has inspired several polemics by physicians in recent years, all of them straightforward indictments of the pharmaceutical industry and its for-profit webs.

Dr. Brody is also a physician, but he aims for the measured cadences of the ethicist instead, calmly laying out the relevant facts and then reasoning from basic principles to determine whether the medicine-pharmaceutical relationship, as it stands now, is an ethical one or not.

That Dr. Brody manages to deliver a hundred-odd pages of determinedly objective analysis before he, too, lets the righteous indignation roll should not really be called a failure of methodology: even as he carefully lays out the facts in this impressively comprehensive book, those facts begin to speak damningly for themselves.

The small-time operations that grew up into modern medicine and Big Pharma joined together back in the late 19th century, allied in the name of scientific medicine against a variety of dubious health-care entrepreneurs. The A.M.A. actually called the early pharmaceutical companies the “ethical” drug makers, to distinguish them from unscrupulous patent-medicine peddlers.

Over time, this casual alliance has been reinforced with such complex and often invisible bonds that, in Dr. Brody’s title metaphor, medicine and pharma are now “hooked” like two pieces of Velcro, tethered by a million barbs and as dependent on each other as any addicts are on their substance of choice.

Dr. Brody systematically analyzes the levels of connection, from the lowly drug salesman buying lunch for a roomful of medical students (future customers all) to the lucrative contracts and patents that simultaneously fuel medical research, fill corporate coffers and give us, as the industry doggedly and quite correctly points out, dozens of truly miraculous life-saving drugs.


CreditWilliam Duke

Many of these interactions are probably now familiar to most readers: the omnipresent logo-bearing trinkets festooning medical offices, the free samples of the latest, most expensive drugs, the “ask your doctor” television ads.

Less familiar may be some of industry’s other friendly overtures: the lavish junkets and cash rewards for some “high-prescribing” doctors; the subtle manipulations of research data; the way-too-generous financing of postgraduate medical education; the very cozy relationship with the Food and Drug Administration and its physician consultants; and a casually Orwellian interference with the average physician’s prescription pad.

A drug salesman recalls for Dr. Brody the time his company asked a local doctor to evaluate various sales presentations for a particular drug: “He’d been selected because our data showed that he was a relatively low prescriber. …Basically, the company was willing to bet $500 or $750 that if he heard the same drug pitch all day, by the end of the day he’d be so brainwashed that he could not possibly prescribe any other drug but ours.”

All this mutual back-scratching would be fine if patients’ interests were indeed being served. But ample data indicates quite the reverse. Patients, after all, are the ones who pay for expensive drugs when cheaper would do as well, and the ones who swallow dangerous drugs nudged to market by their manufacturers.

Many individual problematic drugs make an appearance here. Chloromycetin, a toxic antibiotic from the 1950s, was relentlessly promoted by its manufacturer for routine use until the day its patent expired. (Still available in generic form, it is now used only as a last resort.) Thalidomide never caused an epidemic of birth defects in this country, as it did in Germany, only because a single stubborn F.D.A. officer was dissatisfied with the drug’s safety profile, despite the manufacturer’s repeated assurances that everything was fine.

The epitaph of the recently withdrawn painkiller Vioxx, whose virtues were subtly spun to the medical community in prestigious research journals, is still being written in litigation around the country.

“Research that is driven by marketing rather than by scientific aims would seem, in the end, to be low-quality research,” Dr. Brody comments mildly about the Vioxx fiasco.

His overall conclusion is similarly low-key: “A profession is not just a way of making money; it’s a form of public trust. …Medicine has for many decades now been betraying this public trust.”

It is not a particularly surprising conclusion, and, in fact, there is relatively little in this book to surprise anyone familiar with the territory. Rather than new material, it provides a meticulously referenced compendium of all the relevant history and commentary (including, for full disclosure, excerpts from one of this reviewer’s columns in this newspaper).

Its breadth translates into a lack of depth in some areas, especially the final section, in which Dr. Brody tries to outline a feasible solution to the mess. His suggestions are cogent but a little skimpy, given that absent an act of God, it will probably take an act of Congress to pry medicine and industry apart someday, preferably as part of thoroughgoing health care reform.

Still, for a detailed overview of this very jagged terrain, if not for a map of the pathway out, a better general guide than this one is hard to imagine.

Correction: April 30, 2007
A book review in Science Times last Tuesday about “Hooked: How Medicine’s Dependence on the Pharmaceutical Industry Undermines Professional Ethics,” by Howard Brody, misstated part of the publisher’s name. It is Rowman & Littlefield, not Bowman.

Continue reading the main story

The Dirty History of Doctors’ Hands

The Dirty History of Doctors’ Hands

What the history of handwashing in hospitals tells us about ego and the kneejerk reflex to reject evidence.

In 1846, Ignaz Philipp Semmelweis, a sad-eyed, mustachioed young medical graduate, became chief resident of obstetrics at the Vienna General Hospital. Over the next two decades of his brief career, he became the “savior of mothers” and an enemy of the medical establishment, driven mad by his quest for the truth about hospital-acquired infections.

Semmelweis memorial stamp from Germany
Semmelweis memorial stamp from Germany. Source: “Medicine in stamps-Ignaz Semmelweis and Puerperal Fever” by A.D. Ataman et al.

In the 1840s, teaching hospitals operated by trading free medical care in exchange for the opportunity to practice on poor people. At Semmelweis’s hospital, two clinics ran side-by-side. One clinic trained midwives, and operated with a maternal mortality rate of about one in 25. But in the other clinic, which taught medical students, one in ten women admitted would die before she left the hospital. In some months, nearly a third of the women at this clinic died. The leading cause of death was childbed (or puerperal) fever, and both clinics were referred to in official papers as “houses of death.” But, Semmelweis noted, mortality rates were perplexingly lower among women who insisted on giving birth in the streets and fields of Vienna rather than risk setting foot in the maternity clinics:

To me, it appeared logical that patients who experienced street births would become ill at least as frequently as those who delivered in the clinic. What protected those who delivered outside the clinic from these destructive unknown endemic influences?

Despondent, Semmelweis left for Venice:

I hoped the Venetian art treasures would revive my mind and spirit, which had been so seriously affected by my experiences in the maternity hospital.

But while the art treasures of Venice may have temporarily soothed his spirit, upon his return Semmelweis learned that his close friend, another doctor, had been pricked with a clumsy students’ scalpel in the middle of an autopsy. The doctor quickly became ill and died. Semmelweis wrote:

Day and night I was haunted by the image of [his] disease and was forced to recognize, ever more decisively, that the disease from which [he] died was identical to that from which so many maternity patients died.

In these pre-Louis Pasteur days, the medical establishment didn’t yet know about bacteria. The main preoccupation of the time was with humours and miasmas, and ‘treatment’ for childbed fever involved inducing vomiting, bloodletting, blistering agents applied to the women’s inner thighs, enemas, and liberal use of leeches with the aim of purging the fever heat from the body.

His friend’s death—so similar to the deaths in the medical student clinic—led Semmelweis to hypothesize that the trainee doctors were exposed to ‘cadaverous particles’ in the course of the autopsies they conducted, which they then transferred to the new mothers. The midwives in the neighboring clinic, who concerned themselves only with births, weren’t exposed to these cadaverous vapors. Semmelweis proposed, for the first time in medical history, a connection between touching cadavers and a risk of infection.

Semmelweis decided to act on his hunch. He instituted a clinic-wide policy of mandatory hand washing between cutting up a body and assisting in a birth. “[Hospital staff] had frequent opportunity to contact cadavers. Ordinary washing with soap is not sufficient to remove all adhering cadaverous particles. This is proven by the cadaverous smell the hands retain,” Semmelweis wrote, introducing a chlorinated lime solution to the hospital. It removed the smell of death and would, hopefully, remove the particles too.

In the first three months, death rates plummeted from one in ten to one in a hundred. Semmelweis had shown that he could conquer childbed fever with handwashing.

Semmelweis memorial stamp from Austria
Semmelweis Memorial Stamp from Austria. Source: “Medicine in stamps-Ignaz Semmelweis and Puerperal Fever”by A.D. Ataman et al.

Or so you’d think. In fact, Semmelweis’ arguments were completely rejected by the medical establishment at the time. Coming decades before Pasteur’s germ theory of disease, and without a strong theoretical explanation, his actions seemed to be a reversion to the “speculative theories of earlier decades that were so repugnant to his positivist contemporaries.”

Danish physician Carl Edvard Marius Levy wrote a vitriolic attack of Semmelweis’s findings. First, he deferred to the statistics, blaming the success of Semmelweis’s hypothesis on normal fluctuations of mortality rates in maternity clinics. Next, he argued against the assertion that anything so small as to be invisible could cause death, saying that, “With due respect for the cleanliness of the Viennese students, it seems improbable that enough infective matter or vapor could be secluded around the fingernails to kill a patient.” Lastly, he questioned Semmelweis’s methods altogether: why didn’t he run a simpler experiment, by fully separating those working with cadavers from those aiding in births?

mortality rates

To be fair, Semmelweis did have major faults in his reasoning—he thought that only cadaverous particles caused the fever, and couldn’t explain why some women still contracted fever in the midwife clinic. But, perhaps most importantly, his theories presented a behavioral conundrum for his fellow physicians: testing his hypothesis further could implicate them as dealers of death. Accusing doctors of haplessly causing disease was a slur on the gentlemanly art of medical practice.

Such resistance within the medical community was short-lived. In the later part of the 19th century, a rising tide of empiricism—in particular the work of Joseph Lister and Louis Pasteur—lifted the lonely little ship of hygiene, and the benefits of hand washing would become universally accepted.

But while medical knowledge has radically shifted in the last 170 years, the reluctance to wash hands has persisted. The figures are striking. One large studyfound that hand washing rates were at just 26% in intensive care units, and 36% in the other wards (after monitoring systems were put in place, they jumped to about 50%). Another found doctors self-reported hand washing 73% o the time, but actually only did it 10% of the times they should have. The results are clear: doctors in hospitals not washing their hands kills roughly 100,000 Americans every year and sickens 1.7 million more.

So after 150 years, why is this still a problem? Excuses from doctors range from being too busy, to the washing solution and alcohol rubs drying out their hands, to constantly having to carry equipment which makes it difficult to wash, to hand washing facilities being inconveniently located. Others simply say they forget.

Today, a whole industry of high-tech ways to remind doctors to wash their hands has sprung up, selling hospitals vibrating sensors to remind doctors to lather up, intensive video-monitoring, and incentive schemes for good hygienic practices. One hospital introduced waist-high monitoring that buzzed when doctors walked past without washing their hands. But doctors got down on their knees and crawled under the sensors, just to avoid washing their hands. While busy doctors may occasionally be absent-minded, such reports seem to indicate that sometimes they knowingly avoid it.

Several studies have shown that nurses wash their hands more than doctors. Ironically, part of this may go back to the resistance among Semmelweis’s 19th century peers: It’s speculated that doctors develop a complex of invulnerability—that, as medical professionals, they can’t be harmed or harm others. “The ego can kick in after you have been in practice a while,” one emergency department physician told the New York Times. “You say: ‘Hey, I couldn’t be carrying the bad bugs. It’s the other hospital personnel.’”

Doctors are pretty much universally regarded as empirically-minded. But knowledge doesn’t always translate to universal shifts in behavior—regardless of how easy, necessary, or cheap the solution. The clean, elegant answers produced by biomedical science can’t be found in equal measure in the dirty world of human actions and motivation.

Photograph after a frieze in the Social Hygiene Museum, Budapest. Source: Wellcome LIbrary, London
Photograph after a frieze in the Social Hygiene Museum, Budapest. Source: Wellcome LIbrary

And what about our hero, Dr. Semmelweis? Increasingly obsessive over the years, Semmelweis took his colleagues’ reluctance to accept his theories as a personal affront. Rather than launch a charm offensive to win his fellow obstetricians over, he wrote them abusive public letters: “I declare before God that you are a murderer and [history] would not be too unfair if it remembers you as a medical Nero,” he told one. Increasingly driven mad by the world’s failure to appreciate the importance of hand washing, likely exacerbated by a a touch of syphilis or Alzheimer’s, his colleagues eventually had enough: three obstetricians signed referrals committing him to a mental asylum. One day, while on vacation with his wife and child, he was met at a train station by an old friend who wanted to show him his sanitarium.

Under this pretext, the 47-year old Semmelweis was driven straight to a large, public asylum. He was severely beaten by the guards and died—of an infection—two weeks later.

In honor of Semmelweis’s legacy to medicine, several medical schools, hospitals, womens’ clinics, and museums now stand proudly bearing his name. But, perhaps most appropriately, his name graces the so-called “Semmelweis reflex”: the kneejerk reflex to reject new evidence contradicting established norms.

Leah Ginnivan is a public policy researcher and campaigner with an appreciation for arcane Wikipedia. Twitter: @leahginnivan.