Often, it’s the little things that matter most. That is certainly true when it comes to the economic impact of washing – or not washing – your hands. Soap and water seem like an obvious fix to what ails you, but it’s not quite that simple.

By Zach Sturman ’17

Doctors do it. Nurses do it, too. Schoolchildren line up at the classroom sink every day before lunch and again after recess to do it. Each week you refill the hand soap and hang a fresh towel in the bathroom in anticipation of the scrubbing that’s to come. And the signs posted pretty much everywhere in hospitals and nursing homes prompt us to rinse a little bit longer. Everyone knows that we should all wash our hands regularly and often.

But why? A simple game of “what if” paints a convincing picture. What if no one washed their hands? The outcome could be dire; the ripple effect infinite. Illness and disease could take hold; doctors’ offices could be swamped with hordes of people with runny noses, stomach bugs or worse. And the economic cost from a flood of insurance claims, medical bills and hours lost at work would likely be exponential. A few extra seconds and a squirt of soap are all it would take to stop this potential pandemonium in its tracks.

There’s no question that washing your hands – or not – has a cost and a benefit. And, as I found out researching the subject for my bachelor’s essay, the simple behavior of hand-washing isn’t as simple as it seems.

I stumbled into the world of behavioral economics in the spring of my junior year when I took Principles of Microeconomics, taught by Daniela Goya-Tocchetto, adjunct professor of economics. Suddenly, a whole new world that synthesized so many of my varied interests unfolded before me. Economics drew out plausible cause-and-effect relationships from everyday phenomena. Instead of relying on mere opinion-based rationale, economics seemed to provide new tools for understanding the costs and benefits of particular problems or policies. It unleashed quantitative theory onto a seemingly nonquantitative world of human decisions.

As I delved deeper into this introductory course, I was thirsty to explore each new concept. Podcasts, videos and outside texts started to populate my free time. Then, in the summer after my microeconomics course, I read a macroeconomics textbook at home and even took a standardized CLEP (College Level Examination Program) test through the College Board to get CofC credit for the material. Every new concept seemed to open up another set of doors to explore.

Proper hand-washing can save more than one million lives annually…Even so, hand-washing rates remain demonstrably low and are largely unaffected by traditional education and advocacy measures.

Then, I had a bold idea. I was already required to engage in a yearlong research project as part of the Honors College. I thought, instead of sticking to my political science, astronomy, or Spanish foundations, why not venture into an economics research project? I contacted Professor Goya-Tocchetto about the idea; she was completely on-board, and even agreed to serve as my research advisor. Amid a torrent of all sorts of new material, Professor Goya-Tocchetto mentioned a completely foreign concept to me she thought I might find interesting – behavioral economics. She insisted I look at Cass Sustein and Richard Thaler’s Nudge: Improving Decisions about Health, Wealth, and Happiness; Dan Ariely’s Predictably Irrational: The Hidden Forces that Shape Our Decisions; Daniel Kahneman’s Thinking Fast and Slow; and a host of other academic articles. I went from drinking water out of a straw to drinking out of a garden hose: I was absolutely flooded with new ideas that started to forever change the way I thought. To say the least, I was sold.

In the months that followed, my fascination with behavioral economics grew as Professor Goya-Tocchetto encouraged me to explore my own interests and ideas on the subject. The insights from behavioral economics had wide-ranging applicability. It became clear that the slightest interventions could affect the decisions people make, such as a healthy choice or an unhealthy choice. For instance, one study showed that where an item appears on a food menu affects how often it is ordered. Want to get people to eat healthier options? You might want to start by displaying those items before the unhealthy ones. The same holds true in the school cafeteria. If salty snacks and cookies are the first choices elementary-schoolers see, they will be more likely to choose those options.

In a world where systems appear to be well designed and where we seem to act with complete rationality, the opposite is often true. Instead, how we set up seemingly arbitrary systems can often have significant, measurable effects on human decision-making. In that sense, it is possible to become “choice architects” as Sustein and Thaler describe, and design nudges that affect actions. Based on this concept, we could venture to become our own choice architects and try to strip away some of the potential nonarbitrary choices in real-life settings. All of that is to say my list of ideas for potential research topics started out very long. Eventually, Professor Goya-Tocchetto and I settled on a niche topic: hand-washing.

The insights from behavioral economics had wide-ranging applicability. It became clear that the slightest interventions could affect the decisions people make, such as a healthy choice or an unhealthy choice.

I liked the idea of looking at the behavioral forces behind hand-washing for a number of reasons. First, the data generation was relatively clean, neat and vast. There are several ways you can look at how often people wash their hands: stealthy in-person observations, surveys or indirect means. Based on previous studies, we decided that an indirect proxy, which compares relative soap usage per person, seemed like the best course of action for our sanitary sleuthing purposes. By setting up inconspicuous infrared sensors at the entrances to on-campus restrooms, we were able to get a reading of how many people enter each restroom for a time interval of our choosing. Then, with the help of custodial services and some on-campus partners, we were able to gain access to the soap dispensers and be solely responsible for refilling those machines when necessary. By counting the number of people who used a restroom and comparing that to the amount of soap used for the same time period (by measuring the weight-based amount of soap used),
we were able to get a reliable proxy for approximate hand-washing practices.

Another reason I was attracted to hand-washing was its importance. Proper hand-washing can save more than one million lives annually. Conversely, suboptimal hand-washing practices are a leading cause of death in health care facilities in the developed world, and they are a leading cause of respiratory-induced and diarrhea-related child mortality in the developing world. Even so, hand-washing rates remain demonstrably low and are largely unaffected by traditional educational and advocacy measures.

This interdisciplinary public health topic is ripe for the field of behavioral economics. Certainly, there are psychological forces at play that contribute to the frequency and specific practices of hand-washing. Better understanding of those underpinnings may unlock previously overlooked or undiscovered hand-washing influences that have more general applicability. Perhaps an existing structure in the natural setting of existing restrooms could have an influence on hand-washing frequency. Or perhaps we could introduce an easily deployable design feature that increases hygiene compliance. Whatever the case may be, these questions drive us to keep searching and to keep prodding for answers. In the meantime, I am just so thankful and fortunate to have such a talented, understanding and helpful advisor in Professor Goya-Tocchetto, the support and wisdom of my co-advisor, economics department chair Calvin Blackwell, and to have the possibility of making a contribution in this crucial topic. Hopefully, I can help come up with the next big hand hygiene intervention. Until then, wash your hands.

– Zach Sturman ’17 graduated in May with degrees in political science and Spanish. He served as president of the Student Government Association in 2015-16.

Illustration by Chiara Ghiggliazza.