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Rethinking Hygiene in the United States Context

Updated: Jul 4

NB: This blog was co-written with Ashley Voisinet & Genevieve Mancuso from PHLUSH, and Dr. Terence Lester from Love Beyond Walls.

A hygiene station in the US (Credit:FLUSH/K Worsham)

In May 2024, Vessel held the inaugural US WASH Convening to help unify a fractured US WASH Sector and encourage policymakers to develop a cohesive domestic strategy. This moment presents an optimal opportunity to rethink societal approaches to hygiene and build a strong, independent hygiene component within the US WASH framework that caters to the needs of our most vulnerable populations.

To date, the WASH sector has demonstrated a shockingly narrow mindset regarding hygiene, considering it is only about handwashing. This perspective originates from the context of the international development space, which focuses on hand hygiene to prevent the fecal-oral spread of disease. In a way, it means that hygiene has often been almost an afterthought in WASH endeavors.

During the COVID pandemic, we latched onto this concept in high-income countries, ingraining a correlation between handwashing and hygiene. Although important, this definition greatly limits the scope of the broad and useful concept of hygiene across multiple facets of human existence. It's 2024—we need to get with the times and expand our incredibly limited conception of hygiene in low-income contexts.

A huge part of that will come through reframing how we talk about hygiene. The power of reframing language lies in its ability to shift how we think and act. This shift in narrative enhances our understanding and underscores the urgency of the actions we must take to ensure that people from various social locations have access to what they need. At a recent workshop by FLUSH and other US WASH leaders like PHLUSH and Love Beyond Walls, there was a call to redefine and expand how we think about hygiene in the American context - moving beyond handwashing to consider "wellness" and human dignity holistically.

Redefining Hygiene

The traditional view of hygiene is about keeping your hands and body clean. Sure, that's part of it. But real, genuine hygiene is so much bigger than that. We're talking about environmental cleanliness, such as proper trash disposal, hygiene for menstruation, and food safety practices. Developing best practices surrounding mental health and sleep quality are increasingly within the scope of hygiene. Even good habits around data management and privacy fit under holistic human hygiene, though we won’t necessarily focus on those aspects for now. Hygiene is a broad term for developing good habits across many aspects of life to experience optimal wellness. Reducing hygiene down to just handwashing is not seeing the full picture.

The fundamental reality is that providing water and sanitation services ultimately enables good hygiene for human health. However, the WASH sector has lost sight of that core purpose. They've gotten so bogged down in the nitty-gritty logistics that they've forgotten the "why" - facilitating public wellness through hygiene access.

As participants discussed, hygiene is fundamentally the "why" behind providing water and sanitation services, enabling good water and sanitation practices. We build WASH systems to allow for proper hygiene and prevent disease. However, the WASH sector has gotten away from centering the human need for wellness as the driving purpose. A big part of this reframed hygiene mindset is the need for safe, accessible public spaces for hygienic practices across diverse populations. Reframing immediately allowed us to expand the conversation and include all the ways people need access.

Public toilets with handwashing stations are the most obvious facilities required. For example, one participant noted how essential this need is for the Navajo Nation, which encompasses vast stretches of land with no public services, in contrast to the urban spaces we most frequently discuss in the context of public hygiene. This impacts the tribe’s economy- which relies heavily on tourism - because tourists limit their travel time because there are no restroom stops. But the vision goes beyond just restrooms – because the vision is about overall wellness.

Mechanisms of Hygiene in the US

A major part of achieving proper hygiene is creating public spaces that actually allow hygienic behaviors. Public restrooms with hand basins are obvious priorities. But we need to think bigger than just toilets here, folks. Public bathing facilities- showers or bathhouses, communal laundry stations - are critical infrastructures for populations lacking consistent hygiene access.

In some states like Alaska, having bathing places, whether public showers or bathhouses, is incredibly important culturally and practically. Public laundry facilities and places to wash clothes are another need. The idea is to create public spaces that comprehensively support human wellness and dignity through various hygienic abilities.

And just who are we talking about here? The unhoused, for starters – particularly in urban areas such as Atlanta and San Francisco. Migrant farmworkers in California and the rural Western states. Travelers and truck drivers. Low-income families. The elderly. Gender non-conforming people. People living with disabilities and mobility constraints. Any group whose living situation doesn't provide reliable access to basic hygiene services. We're failing a massive portion of the US population.

Barriers to US hygiene

Improving hygiene equity won't be easy - there are major barriers to overcome:

First, building and maintaining public hygiene facilities, especially in poorer areas, is no small expense. Sadly, funding is often blocked by absurdly restrictive eligibility rules written by bureaucrats that are completely disconnected from reality.

A "No Pubic Restroom" sign in NYC (Credit:FLUSH/K Worsham)

We're also dealing with a serious staffing shortage regarding personnel to run these operations. Social stigma and the targeting of specific groups, such as those who are unhoused, along with a lack of proximity to the real-time needs of people, still exist around hygiene needs. These factors cause decision-makers to fail to understand, thus prolonging implementation or preventing action in certain parts of the country. And certain cultural stigmas still exist around hygiene needs that decision-makers fail to understand. For example, those with religious obligations to hygiene, like practicing Muslims, need foot baths, ritualistic handwashing, and Jewish purification baths like mikvehs.

Perhaps most importantly, there is a lack of unified responsibility and prioritization for public hygiene in this country. Different agencies, such as parks departments, transportation, and public health - all are great candidates who own the issue or at least collaborate to bring these services to the public rather than fighting over them. But in most cities and towns, public facilities never find their way onto the budget of any city department. It's a jurisdictional mess with no clear leadership - something we have seen some low- and middle-income countries figure out how to better consolidate.

If we actually want to make progress, metrics, and accountability are key. We need to measure comprehensive data on public facility access, space beautification, and public health impacts. We may need a new "Wellness Index" quantifying human dignity and hygiene fulfillment. A mix of data and storytelling may be needed.

We've got to fix the linguistic framing because calling this "hygiene" is part of the problem. Wellness is a more holistic concept that reframes it as a human need. Some nations, such as Brazil, Norway, Germany, and Ecuador, have even codified wellness as a fundamental human right — a model we should explore.

Making more wellness in the US

Ultimately, ensuring public hygiene - or wellness - for all is an equity issue of the highest order. It's about providing human dignity and health for society's most vulnerable populations. The WASH sector in the United States must evolve past the limited handwashing-only mindset. If we do not progress and broaden the conversation to encompass overall wellness, many people will continue to lack access to critical resources that contribute intrinsically to human dignity. We need a more holistic, equity-driven approach centered on public wellness through hygiene across all aspects of life. Creating an intersectional culture of care around safe, accessible public spaces is critical.

And we know it isn’t impossible. Eastern cultures have incorporated hygiene into their daily lives: depending on the culture, indoor-only shoes may be used, bathing before sleep may be prioritized to keep linens clean, and bathhouses may be prevalent in public spaces. The cultural context around hygiene is important to consider, and in areas with greater success in this arena, the ingrained “hygiene culture” is often rooted in religious or spiritual practices.

On the other hand, the US is dropping the ball on hygiene, all because of an archaic, handwashing-level understanding of hygiene from a bygone era in the WASH sector. Although we are far from prioritizing hygiene in this country, it is still possible to begin a paradigm shift to the comprehensive wellness mindset required to increase the number of public bathhouses, dignified restrooms, and community hygiene hubs. It begins with placing a societal value on these spaces and the wellness they provide. Deprioritizing this is a moral failure.

If we start prioritizing wellness access for those most in need, the benefits will extend to everyone. It's that simple. So, let's get our acts together and bring public hygiene squarely into the 21st century, shall we?

Special thanks to Laura Brunson from Water for People for a fruitful conversation about this before posting.

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