When a handshake can kill you...

As a doctor I greet many people, both new and familiar, every week, and inevitably we shake hands. It would feel awkward not to do so. This is the way I was brought up, that a firm handshake is a mark of strong character, part of the process of creating a good first impression, and that there is no second chance to do so. Occasionally it goes wrong, and the hands presented do not meet in the right manner, leaving one with that awkward and limp “fingers trapped” feeling. I never know whether it was my fault, did I not aim correctly or was I just careless in this first moment of meeting?

I know someone who does not shake hands. She “fist bumps” instead. At first meeting she will tell someone “Sorry I don’t shake hands, it’s just a thing I have, but let’s fist bump”. No one forgets this, and it’s amazingly easy to do. We see sportsmen doing it all the time, and it’s from there that the fist bump’s popularity has grown. It’s impossible, unlike the handshake, to get it wrong.

The commonest reason given by an individual for not shaking hands is a germ phobia, the fear of catching or picking up an infection from another person. If that is the case, then a fist bump is a very sensible alternative, and there are new studies to prove it. A fist bump spreads 90% fewer bacteria than a handshake, compared to 50% fewer with a “high five”.

Now it is reasonable for most of us going about our ordinary lives that we really do not need to worry too much about this. Most bacteria are good, and should be left alone. But life can at rare times become extraordinarily dangerous and little things like not shaking hands can be very important.

Take the recent Ebola outbreak in West Africa for example. Ebola kills between 60% and 90% of the people it infects, and spreads from person to person via body secretions. Most worryingly a person who is infected can take up to three weeks to become ill, and during that time a little thing like politely coughing into one’s hand — as one does if taught good manners — and then shaking someone else’s hand thereafter can spread the virus. A fist bump would cut this risk by 90%. No wonder there is great cause for concern and urgent measures being put in place internationally to contain the spread of Ebola.

The current loss of life due to Ebola is miniscule compared to the estimated 100 000 people who die from hospital-acquired infections every year in the US alone. The antibiotic-resistant bacteria responsible spread from patient to patient predominantly through human contact, with scrupulous hand washing by staff and visitors being the single most important means of fighting spread of infection. But other vectors of spread are also to blame, such as hospital prescription charts handled by everybody in the patient’s chain of care, from doctors to nurses to hospital porters and pharmacists. Not many people think to wash hands before and after picking up a prescription chart. Other items to blame for hosting harmful bacteria in hospital settings are mobile phones, computer keyboards and even doctors’ ties. It may be a very small contribution to limiting spread of infections, but substituting a fist bump for a handshake if you simply have to make body contact with a doctor, nurse or loved one could well be a life-saving measure to someone else.

Even outside hospitals and areas going through disease epidemics, there remains the risk of the next global killer infection. The Spanish flu of 1918 killed up to 100 million people, significantly more than died in WW1. The likelihood of another equally virulent infection arising one day is not a matter of “if” but of “when”. There have been smaller-scale “warning” outbreaks like that of the Sars virus in 2002 that killed almost 800 people, spreading in the same manner. Compounding the risk is the ease of which humans travel around the world by modern travel. The flu virus of 1918, if arriving new under today’s circumstances, could arguably be the biggest global catastrophe and threat to human life ever known. Little things like learning how to cough safely and not shaking hands would be critical measures on a global scale.

I don’t believe paranoia is generally useful, but the one area where I am paranoid is the public toilet exit door handle. That to me is an “avoid bare skin contact at all costs” area. Because everybody coming in (potentially carrying, for argument’s sake, Ebola, Spanish flu, hospital-acquired bugs, you just don’t know) touches it on going out.

And if you do, and we meet, please don’t think I’m rude, but I’d far rather fist bump than shake your hand.