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COVID-19

The end of the handshake?

In the time of a pandemic, societies adopt practices that necessitate the least human contact. To curtail the spread of coronavirus disease 2019 (COVID-19), people have transitioned to social distancing and replaced gestures of greeting and parting for an alternative acknowledgment. In the early days of the pandemic, people were waving, bowing, foot tapping, and elbow bumping. It is difficult to predict how COVID-19 will reshape social etiquette. Perhaps alternative greetings will define a new normal for social interaction.

The handshake transcends culture and geographic boundaries. Its origin is found in ancient Greek history as a gesture representing an offering of peace. In modern times it symbolizes greeting, establishes respect, offers congratulations, and solidifies farewell.

Although hand hygiene is a recommended guideline for infection control, its practice is variable. Health care providers maintain an average adherence rate of only 40%. A study that directly observed hand washing after restroom use found that 67% of individuals used soap when washing their hands, 10% did not wash their hands at all, and only 5% washed their hands for the recommended duration. A handshake can transfer 124 million bacteria, twice as many pathogens as a high five. Contamination is associated with the area of contact, and the largest contact area is obtained with a handshake. We may benefit from avoiding hand contact altogether.

The pandemic has inspired creative alternatives. Some advocate for noncontact greetings such as a wave or customary bowing. A study concluded that within the health care setting, 78% of patients prefer that their physician greet them with a handshake. The foot tap involves individuals tapping their feet together to greet. The elbow bump may be less than ideal considering that some societies advocate for people to sneeze and cough into their elbow.

The fist bump transmits the lowest number of pathogens in comparison to a handshake and high five. Among volunteers on a surgical ward, the colonization of the palmar surface of the hand after a handshake was four times greater than that of the fist after a fist bump. The fist bump is derived from dap, a language of gestures rooted in Black American history. It emerged in the 1960s among Black soldiers during the Vietnam War to establish unity in a time of racial tension and discrimination. Dap is an acronym for “dignity and pride” and symbolizes solidarity, a pact taken among soldiers vowing to look after each other. Since then, the fist bump has found a place in popular culture and even in health care settings as a more hygienic practice.

A reasonable substitute for the handshake should maintain the essential qualities of a handshake. A new custom should continue to use the upper extremity as many are accustomed to this practice with shaking hands and embracing. It should also allow individuals to face each other to maintain eye contact. When applicable, the gesture may involve brief contact, as human touch is fundamental in communication and vital in human connection, and it conveys kindness and compassion.

We propose a new two-part greeting that establishes rapport without hand, elbow, or foot contact (see the photos below). The first part does not require contact and can be performed to acknowledge another at a reasonable distance away—an ideal gesture in a time of social distancing. An individual may simply place their closed fist to their chest just overlying the heart to convey greeting. The second part may be performed only when contact between two parties is permitted. In this scenario, after an individual has placed their fist to their chest, they may extend the forearm outward at a 45° angle. The reciprocating party positions their arm alongside the initiator’s arm, and together, they briefly tap their mid-forearms, forming a cross-like configuration. Important components of the greeting include positioning the palm to face away and making a fist, which directs contaminated fingertips away from others. The cross-like configuration permits the least area of contact, and the brief tap of the forearms minimizes contact time.

Cato T. Laurencin

We advocate for adapting to the changing times and altering practice accordingly. This is one idea. The handshake is engrained in many societal practices, and perhaps the changing times have called for a new symbol that conveys strength, maintains solidarity, and ultimately facilitates our healing.

Cato T. Laurencin is the Albert and Wilda Van Dusen Distinguished Endowed Professor of Orthopedic Surgery and the chief executive officer of the Connecticut Convergence Institute for Translation in Regenerative Engineering at UConn Health, Farmington, Connecticut, USA. He is the University Professor at the University of Connecticut, Storrs, Connecticut, USA. laurencin@uchc.edu

Aneesah McClinton is a research fellow at the Connecticut Convergence Institute for Translation in Regenerative Engineering at UConn Health, Farmington, Connecticut, USA. mcclinton@uchc.edu