Living in an eight million-sized metropolis can be an excellent opportunity for watching people and learning about their dynamics. It can also mean a lot of germs in your surroundings, and personal space. 

So if we combine both facts, it becomes easy to understand that the survival instinct in people often leads them to react to the idea of being around germs to keep them somehow protected. Whether they can indulge themselves with an acceptable environmental hygiene level is not always guaranteed though.

But as a hub for millions of tourists, visitors, and residents, who spend a considerable amount of time either shopping or trying the authentic dining experience, New York City is certainly the place to look out for hygiene in restaurants and shops, as a part of the city’s (and nations’) public health. I am particularly speaking of the hygiene of doors’ handles as a disease transmission prevention strategy.

 Over its years of governance, the Bloomberg administration established itself  as a national leader of public health efforts, or a ‘public health autocrat’ as policy wonk Ezra Klein describes the person of Mike Bloomberg.

From the smoking ban in all NYC bars and restaurants in 2002 and later beaches and parks in 2011 , to the ban of trans-fats in all foods prepared in NYC restaurants, followed by the calorie-posting requirement by all chain restaurants, and the latest proposal for banning the ‘Big Gulp’ sugary sodas that is still drawing heated debates city-, state-, and nation-wide, Bloomberg has certainly succeeded in reflecting the American fight against the nation’s big health burdens like obesity, smoking, and pollution.

Most of these targeted risk factors, however, are ones that increase the risk of chronic diseases like diabetes, cancer, heart diseases, etc., which indeed make up the biggest burden of deaths in the country. It has also become secondary when living in the developed world to worry about infectious diseases that usually concern the underdeveloped countries. Tuberculosis, malaria, hepatitis, and others are not in the top 10 health issues of Americans, thanks to intensive immunization and health care during the end of the last century. That said,  it does not preclude that in 2012, people in big cities like New York are still exchanging germs, all day, every day, and in an uncontrollable fashion (‘Contagion’ movie, 2011, is a realistic scenario and a great mind-refresher of how easy it has become for a germ to travel the world and cause a pandemic).

In epidemiology, contact transmission is one of the most common forms of disease transmission. In the present case, we are talking about an indirect transmission from the host to the healthy person through infected surfaces, doorknobs and handles. The probability that a person in New York City contracts an infectious germ every time they touch a  door handle can be calculated using a simple mathematical equation. It is the probability that the person touches the door handle when they open a door times (x) the probability of having an infectious/pathogen germ on that handle. To make it simple, let’s assume that once an infected door handle is touched, the germ will be taken up by the person. The number obtained from this equation can then be multiplied by the average number of doors opened by the person in a day to get an approximation of the daily probability of being at least ‘endangered’ by a germ. 

The number of germs on door handles cannot be easily controlled (public health departments have been trying to curb it by encouraging the display of dispensers of sanitizers by doors for voluntary use), nor the number of times a person opens a door per day. The only variable a public health department can actually control is the probability of touching a door handle surface (when opening that door) that will potentially carry transmittable germs (i.e., the first arm of our equation).

How easy would that be? In fact, easier than any public health effort I have ever heard of. It is called: Foot Handle.

The best argument I would give in favor of requiring the presence of this tool on public doors is that a government can not force  infected people to wash their hands or not spread their germs, however the government should be able to provide  their healthy counterparts with an option to protect themselves from becoming infected.

Why is a foot handle needed, why is such a governmental intervention feasible, and what are the available options and alternatives in the market?

1- Need/Importance: If only influenza is considered as the infectious germ in the city, the foot handle makes a very solid case. But to  make it a bit more realistically complicated, it suffices to calculate the number of combinations of  people that touch one door handle every day and the types of germs they likely carry on their hands to get an idea about the diversity of germs that can be found on restaurants’ and shops’ front- and bathroom- doors.

With increasingly resistant and mutant pathogens in our environment, vaccines and antibiotics still face failure sometimes in helping people fight against virulent germs. Influenza viruses, for example, are constantly changing, and flu vaccines must be administered annually. Preventing contact transmission of the virus to a healthy host is easier and (maybe) more cost-effective than immunization. It can also be seen complementary to immunization as a primary prevention method.

Another issue that raises environmental concerns is fecal germs, which are highly likely to be found on door handles of public bathrooms. A panoply of fecal bacteria, protozoans, and intestinal parasites (worms) have their life cycles re-initiated when the germ or the egg of the parasite finds its way from the feces of an infected person to the mouth of the next host. As odd as it sounds, the fact that these parasites still exist and invade our systems means that their feces-to-mouth transmission is happening. Consider the following scenario:

“Emma is infected by an intestinal pathogen A.  She uses the public bathroom in a shopping mall and decides to be lazy about washing her hands. She walks away leaving an infected door handle behind. Madelyn, a shopper with germ phobia OCD, who has just finished using the bathroom and washed her hands thoroughly, still had to touch the same handle to leave the room. Pathogen A was lucky enough and made its way to her right hand, the one she used to open the door.  By simply touching her face, germ A was internalized in Madlyn’s digestive system. Germ A was very pleased to find that Madlyn did not have all that excellent immune system after all, and the power to cause her illness seemed granted. An additional sick person was added to the world, with additional healthcare costs, morbidity, and maybe mortality.”  Scenario closed.

Like any other public health policy, the present policy discussion begs the question: is it proven to be effective? And if so, will it be effective in practice?   My research shows that no studies have been conducted till day to answer either of those questions. One study published in 2011 tried to understand how mechanically feasible is opening the door using a certain foot handle design. However, what is well established is that door handles bear a high risk for germs’ transmission, particularly for germs from which only a few particles or cells are sufficient for infection, like EHEC (E.coli) and Norovirus (Source).

What remains to be scientifically answered is whether people would use foot handles when they are present, and if their presence on doors will have a significant effect on disease transmission. A powerful marketing campaign should eventually accompany the implementation to  increase community education and adoption.

2- Feasibility: The most challenging part of doing public health advocacy  in ‘Corporate America’  is the conflict of interest (COI) that often faces health advocates and impedes their efforts.  In fact, lobbyists can fight for years over a health policy or law. The advantage of foot handles policy is that it is almost devoid of COI.

  • First, foot handles are not to replace traditional door handles, they are there to complement their task. Therefore, manufacturers will not be losing any of their business, and hence do not have a reason to oppose the intervention. If anything, they should be thrilled about new opportunities to be expanding their business into new lines.
  • Second, restaurants and shops, unlike most of the other health laws championed by the mayor, are likely to lose zero profit in consequence. Banning indoor smoking, for example, has always been associated with the fear of losing smokers as customers. In this case, the intervention does not infringe on people’s ‘freedom of choices’, and is not expected to trigger fear of losing business.

Outlook: In fact, I see it to be very attractive to both the public, and businesses. Given the hygienic nature of the foot handle, increasingly health-conscious people are expected to heartily welcome the idea. As for businesses, foot handles are relatively cheap, with only a one-time implementation cost, and somehow gives NYC venues an avant-gardist healthy edge.

One last fact that increases the feasibility of this intervention:  foot handles are already in the market; so no need to start from scratch.

3- Options and Alternatives:

-The Toepener is a new startup launched in 2011 by a group of college students from the University of Minnesota Carlson School of Management. The foot handle has been featured as a top entrepreneurial college project by many business and media platforms. The design is simple and can virtually apply to any door, allowing users to pull the door with their foot and exit, hands-free. It is selling for 49.95 USD, with many success stories from customers.

-Another company, StepNpull,  based in Missouri has also developed a foot-handle model, priced 29.95 USD.

Footpull was also developed for the same purpose (Price: 42.00 USD). The tool is now found in big chain restaurants like McDonald’s, Wendy’s, IHop, and Hooters, in addition to many US centers, hospitals, and universities.

There are also some cool designs,  that involve using the wrist instead of the foot, like Wristpull. However, given that the foot is more distal than the wrist to the face (i.e. the mouth and the nose),  the foot-handle is probably the safest option of all. In fact, the odds that a pathogen travels from one’s foot to their face are much less than from their wrist to their mouth or nose.

The only downside of the tools above is that they do not provide a lock/unlock option to a door; instead they apply to outside bathroom doors or shop doors that are supposed to be pulled but do not require to be unlocked.

Manufacturers should probably customize their tool designs to allow them to grip internally to door locks, and be used to open doors with locks. In NYC for example, many restuarants have only one bathroom, and its door must be unlocked (i.e. by touching the handle surface) after washing hands, unlike larger restrooms that have external doors; the available foot handles are probably not effective in this case.

Many approaches have been invented to try to overcome this public health problem, like handles with built-in dispensers,  disposable handle covers, or simply man-improvised use of paper towel as a self-defense mechanism. However, none of these alternatives seem to be eco-friendly or sustainable as they need regular supply of detergents and towels, and cost much more than a one-time implementation handle. In addition, many germs, like Norovirus for example, are less susceptible to alcohols and detergents as they do not have a lipid envelop in their structure.

We have all heard of the urban myth that ‘NASA spent billions developing a pen that functions in space, whereas Russians used a pencil’. There is certainly value in using a simple and elegant solution versus a complicated one in order to improve our daily lives and the public health, and I do not see one reason why New York City, the city of the empire state, still does not have this miraculous solution.

From a reform enthusiast and a NYC lover…