From twilight to limelight

By Prof Wendy Graham
Twilight moving from twilight to limelight

2020 is proving to be quite a year for us all: a global pandemic, the international year of the nurse and midwife, the bicentenary of the birth of Florence Nightingale, the passing of a modest philanthropist, and the 120th anniversary year of the opening of The London School of Hygiene & Tropical Medicine (LSHTM). And what is the theme linking these? The answer - cleaning.


200 years ago, Florence Nightingale was born and 80 years later, the London School of Hygiene & Tropical Medicine was opened. And this year, Florence’s name has been added to the LSHTM frieze of heroes of public health, in acknowledgement of her contribution to elevating the importance of preventive hygiene – of “first do no harm”. Her Notes on Nursing, published in 1859 provide many examples of modern relevance regarding infection prevention and control (IPC). 

"Every nurse ought to be careful to wash her hands very frequently during the day” 

Florence Nightingale, Notes on Nursing

LSHTM itself has a long and illustrious history of work on the very basics of public health – water, sanitation and hygiene (WASH) practices, though in recent years most of this work has focused on issues in low and middle income countries (LMICs) rather than the UK.  In a previous blog, I posed the question of Where is the H in LSHTM?” and called for a stronger profile for the quiet work behind the scenes – including during the COVID-19 pandemic, to understand the barriers to effective IPC and WASH in healthcare facilities where risks to patients and staff from healthcare-associated infections (HAIs) were enormous even before the current pandemic.

But it was our creation of a small charitable Trust – The Soapbox Collaborative – which has particularly helped to shine a torch on the neglected area of environmental cleaning. This initiative ran for 7 years, from March 2012-June 2019, and its legacy lives on at LSHTM. It was the generosity of a retired Scottish nurse-midwife that enabled Soapbox to be set-up and to conduct research and action to reduce HAIs in maternity units in LMICs. Miss Elsie Duguid was born in 1921 and trained at Aberdeen Royal Infirmary, where she became a passionate advocate for hygiene – along the lines of Florence Nightingale. A rare photo can be seen of her here in this collage of images from Soapbox’s work (right side, three photos from the top).

Soapbox collaborative montage

As a very modest person, Miss Duguid wanted no acknowledgement in her lifetime of her financial contribution to Soapbox, and remained very proud of one of its main achievements – a training package TEACH CLEAN for low-literacy cleaners. Miss Elsie Duguid sadly passed away on May 19th 2020, aged 98.

Just two days later on May 21st, at the side meeting of the virtual World Health Assembly for 2020, there was an opportunity to emphasise again the importance of cleaning and cleaners. This marked one-year on since the WHA72/7 Resolution on WASH in HCFs, at which I presented the “gold mop” award to the Director-General - in recognition of his support for the neglected cadre and activities of cleaners.

Presenting the “gold mop” award to the Director-General - in recognition of his support for the neglected cadre and activities of cleaners.

In 2019, cleaning was still in the twilight of attention at all levels – within facilities, nationally and internationally. Who would have thought, 12 months on, that the crucial role of these frontline health workers would be catapulted into the limelight by a global pandemic?

And the attention extends beyond healthcare facilities out into everyone’s home and into public places and spaces. With cleaning becoming a universal concern, our Safe Surface Science webpages give us a chance to share the latest evidence. From the terminal cleaning of wards, to the extra PPE worn by cleaners, to the wiping down of shopping trolleys, to the stock-outs of household disinfectants, and to the cleaning of public transport – we see evidence that the “clean revolution” we called for in May 2019 is underway

And I am witnessing this close at hand as I return after many years to work in a hospital, and on a ward with patients with COVID-19, where every time I don and doff my PPE, I realise how lucky I am to be protected by the hard work of the incredible hospital cleaners.

Wendy in her personal protective equipment

But where heightened cleaning is needed the most – in high density environments (clinical and domestic) for populations with poor overall health status and greater risks of all HAIs - there are still too many obstacles. Finance, supplies and trained personnel remain serious challenges.

Whilst it is inexcusable that a global pandemic was needed to bring this issue from the twilight into the limelight, the bigger question is how to prevent it from returning to the shadows after COVID-19. How do we ensure that no-one in the future is deprived of the most basic right to protection from cleaning and cleaners?


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