Prevention, Germs, and Dirt: Looking for the Sweet Spot

Losing sight of what’s truly best for our health on our “quest for clean”

wash hand
MakiEni's photo / Getty Images

One of the greatest advances in the history of public health is stunningly humble. It was not the product of a great invention, novel technology, or the Nobel Prize. It was the simple insight that cleanliness matters. The advance was sanitation.

Sanitation, in both its private and public manifestations, has saved untold lives. The private practice of sanitary medicine—hand washing, essentially, and subsequently all of the antiseptic practices that evolved from there—traces its origins to Ignaz Semmelweis, a Hungarian physician in the 1800s who introduced handwashing guidelines to obstetrics clinics.

The initial beneficiaries were his obstetrical patients, who experienced reduced rates of illness as a result. But once the benefits of what was then a controversial practice became clear, all of medicine cleaned up its act—or, at least, its hands.

Of course, we were again reminded of the importance of hand washing with the shigella outbreak in Flint, Michigan in fall 2016. The infamous water contamination problem there has scared residents enough to not only avoid drinking the water, but washing with it, resulting in a severe gastrointestinal infection that good hygiene could otherwise prevent.

The impact of public sanitation was likely even greater, and traces its origins to the insights of epidemiologists dealing with urban squalor in the mid- to late-nineteenth century. The connections between concentrated filth in densely populated cities and infectious disease outbreaks became increasingly clear, and eventually gave rise to aspects of urban planning we take for granted today, such as sewer systems and indoor plumbing.

The number of lives saved over the decades since is all but incalculable.

There have been many lists compiled over recent years that note the greatest medical and public health advances of all time. I looked over quite a few, and both basic sanitation and antiseptic practices in medicine make the top 10 on almost every one of them.

There’s another one that also tends to make everybody’s top 10, and it’s related: vaccines. Vaccines, or more correctly, immunizations, have also saved countless lives and even produced the first intentional “extinction” in the natural world: eradication of the smallpox virus.  We’ll come back to immunization momentarily.

Sanitizing Overload

But first, we all know the saying that too much of even a good thing may no longer be a good thing, and in the modern era, that may be true of sanitation.

You pretty much have to be living under a rock these days (where, by the way, the exposure to some dirt might be good for you!) not to have heard about the “microbiome.” As you likely know, this refers to the community of bacteria that live in and on us, and contribute mightily to every aspect of our health. By most estimates, there are at least 10 bacteria living in the community that makes up a single human being for every “human” cell, so we are something of a rounding error in our own skin. We have more bacteria than human DNA in our bodies.

The effects of the microbiome on health is a lengthy article in its own right. The point here is simply this: We’ve come a long way from the days when “the only good germ was a dead germ.” We now know that some so-called “germs” are friend, not foe, and vital to our well-being.

We also now know that we are paying a high price for getting carried away in our enthusiasm for sanitation. The modern microbiome, because of lack of exposure in early childhood to what we might call “good, clean dirt,” the germs of other children, and even those of animals, is often impoverished relative to that of our ancestors who lived before Lysol. There is ever more evidence that everything from allergies to asthma, autoimmune diseases to even diabetes may be explained by this trend.

Our zeal for use of antibiotics has created a parallel problem: antimicrobial resistance. The emergence of “super bugs” none of our antibiotics can kill is partly the result of injudicious use of antibiotics in medicine, often for viral conditions that didn’t require them; widespread use of antibiotics in feed animals, often just to make them grow fast and fat; and antibiotics present in routine, household products (notably, in antibacterial soaps, hand sanitizers, and cleansers).

Concern about antibiotics everywhere has grown acute. The food industry has taken notice, and ever more producers are committing to antibiotic-free fare. The FDA is directly involved as well, and it recently banned an array of antimicrobial soaps. The agency expressed concerns about the safety of some widely used antimicrobials in household products and doubts that they are more effective at preventing infections than just plain soap.

Redirecting Our Focus

But here’s where immunizations come back into the discussion. While we have done some damage getting carried away with our antiseptic enthusiasm, no one should think we were better off when smallpox was a universal fear, and every spring brought the threat of polio. Along with sanitation, immunizations have their rightful place on the list of greatest health advances of all time.

But these days, we have grown complacent about vaccines at best, and at worst, have talked ourselves into opposing them. This is a serious mistake. I want to be perfectly blunt about this, and not just as a doctor, but as a fellow human being with his own sleeve to roll up—and as a fellow parent who has had to put the skin of his own five kids where his mouth now is: Immunizations save lives.

The only reason we are now prone to be more afraid of vaccines than the diseases vaccines prevent is because vaccines have done such a magnificent job preventing diseases that we have forgotten about them. Fear of vaccines tends to be the luxury of populations spared the terrible diseases they no longer get because of vaccines.

Dirty vs. Clean: Striking a Balance

Where this leaves us is on a middle path where prevention benefits from both the right dose of both sanitation and dirt. We do not want antibiotics in our food or environment, and we should not take any we don’t truly need. Exposure to dirt, and even germs, is normal and healthy both in childhood and after.

For those of us who don’t find all the friendly bugs we need that way, a probiotic is apt to be a good idea. But there are still dangerous and preventable infections out there, influenza among them. We let down our guard at our peril.

My advice is to roll up our sleeves, wash our hands, get our vaccines—and put away the antimicrobial soap.

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