Washing our hands has become one major way to protect ourselves from Covid-19. However, ablutions have always had a central place in the practices and beliefs of many religious traditions. Christians perform baptism with water, in amounts varying from small sprinkles to larger vessels, to bring about purification, cleanliness, revival, and rebirth. Jesus’ washing the feet of his disciples as narrated in the Gospel makes the washing of feet an important practice in Christianity to promote cleanliness and is still carried out to this day. The Jewish tradition also has many instances of ablution where water is specifically used to promote cleanliness, including washing hands to reclaim or preserve purity and mikveh in which the feet or whole body is immersed in water.

The Islamic ablution, also known as “wudhu,” contains 24 washing movements to be carried out several times a day for the five daily prayers. If performed for all five prayers, it would consist of about 120 repeated actions as Muslims washed parts of their body.

A lover must undertake the required preparation to cleanse and beautify oneself before meeting with their Beloved. Likewise, a believer is required to wash specified parts of their body to stand before God in supplication, as instructed in Chapter Maidah of the Qur’an, verse 6: “O believers, when you stand for prayer, wash your faces, and your hands up to the elbows, and wipe your heads, and wash your feet up to the ankles. If you are unclean, bathe and purify your bodies fully. But if you are ill or in the middle of travelling or … you cannot find water, then take wholesome dust and wipe your faces and hands with that. For God does not wish to burden you, rather He desires to purify you and to complete His blessing and favor upon you so that, perhaps, you may be grateful” [5:6].

The spiritual cleansing that the act of wudhu provides is highlighted by the Prophet Muhammad (pbuh) in numerous hadiths, or prophetic sayings, which has been collected under The Book of Purification. While water literally cleans the face and limbs, with every pure intention to do wudhu, the water droplets that meet the body also wash away the minor sins that were committed by the hands, mouth, face, ears, and feet. The famous hadith that “cleanliness is half of faith” [Sahih Muslim, 223] can be interpreted as applying primarily to doing wudhu in one translation [Wudhu: Fiqh, Rules, Purification and Blessings, Qadri]. Therefore, to perfect the faith, to be cleansed of our mistakes continuously, God has given us a simple mechanism through which to be purified and recalibrated countless times in a day.

Many of us perform this pattern of washing with little thought. It has become a routine that we seldom consider a medical protection that we apply to our body. Besides its effects on the soul, washing also has wonderful effects on the body. Over fourteen hundred years ago, the Prophet (pbuh) advised ablution before going to bed. Interestingly, yoga experts in recent years have also started to encourage the washing of the legs, hands, arms, eyes, and the mouth before sleep with cool water for a deeper undisturbed sleep. This is not surprising considering the relief that comes with the touch of water on a busy day.

Three of our principal systems benefit from wudhu; the circulatory system, the immune system, and the electrostatic balance of the body. In this way, the health benefits from the ritual of washing are threefold…

Circulatory system

The circulatory system is a magnificent circuit of blood vessels between the heart and the tissues that make up every other system of the body. The systemic circulatory system circulates oxygenated blood from the heart to the tissues around the body and back to the heart, whilst the pulmonary circulatory system transports deoxygenated blood to the lungs for detoxification and returns clean blood to the heart. The correct functioning of the blood vessels, which act as wires that connect our major organs, are essential to the efficiency of this circuit. These vessels divide into thinner branches called arterioles which in turn split into smaller capillaries which surround the cells of the body. The vascular resistance generated by blood vessels is overcome by the blood pressure generated by the heart to enable blood flow. Over time (due to ageing, or a diet high in fat), our blood vessels often harden and become constricted meaning that the heart has to work harder to overcome increased vascular resistance to maintain steady blood flow. The vessels in the limbs are the most peripheral to the heart and thus the most vulnerable to the process of hardening and narrowing over a long period.

The application of water in our daily routine “exercises” these blood vessels by alternately contracting and dilating them. Water can act as an agent of temperature gradients, thereby affecting the thermoregulatory response of the cutaneous circulation. When hot, water ensures that vessels in the limbs dilate, and when cold, that they contract. In this way, water ensures the flexibility of vessels distant from the heart, forcing nutrients deposited in tissues as a result of poor circulation back into the bloodstream through a temperature gradient.

Lymphatic system

The lymphatic system, on the other hand, is probably not the first to come to mind when we think of the body’s organ systems. Yet without this quietly working system our cardiovascular system would collapse and our immune system would be impaired. Our lymphatic vessels transport “leaked” blood fluids into our capillaries to prevent the accumulation of fluid in the interstitial spaces and eventual tissue damage. The vessels of the lymphatic system are much thinner than those of the cardiovascular system, ensuring the circulation of white blood cells which have an essential role in protecting the body against invaders and resisting disease. It is this fluid that we see oozing out when we have a cut or wound.

The optimal functioning of this system and its thin vessels, like those of the circulatory system, can be said to be closely linked with the effect of washing. The phagocytes and lymphocytes, which make up the immune system are housed by our lymphoid tissues and organs, are supported by the act of wudhu. The nasopharyngeal region behind the nose leads to the tonsils, which are small masses of lymphoid tissue that trap and remove pathogens that are entering the throat. Washing the mouth and nose three times with every wudhu therefore helps to remove the bacteria that builds up in the region of the body most exposed to the external environment. Moreover, the act of washing both sides of the neck during wudhu stimulates our cervical lymph nodes – a specialized mass of tissue which houses lymphocytes and particularly helps to protect the body by removing bacteria and tumor cells from lymphatic circulation. Our lymphocytes are arguably the most important component of our immune system, patrolling every point of the body many times a day and destroying cancer cells and pathogens along the way. Considering that the act of wudhu enhances the filtration effect of our lymphoid circulation, one can see the blessings that come with the divine command to “wash…and purify your bodies fully….”

Electrostatic balance

Our physiology is also closely related to the electrostatic balance of the body. While many psychosomatic diseases result from electrostatic imbalance, the most pronounced effect of static electricity is exerted on the subcutaneous muscles located under the skin, mitigating their function and inducing the onset of wrinkles which often start in the face. Maintaining the regular habit of washing the skin – particularly the face which is most frequently exposed to ultraviolet radiation – protects the surface and internal layer of our skin cells by constantly dampening the skin surface with clean water. It is a much simpler alternative to spending hundreds and hundreds of dollars on expensive skin care and makeup products to maintain a healthy complexion.

In regards to how wudhu can benefit our electrostatic balance, the part of the verse which sheds light to tayammum, “if you cannot find water, then take wholesome dust and wipe your faces and hands with that” highlights that the water substitute for wudhu significantly reduces static electricity, like water. This is why when wudhu is performed calmly with care, it often leaves one feeling refreshed and discharged.

The Quran is a grand source containing many prescriptions for good health. While every civilized person may wash their face and hands throughout the day, wudhu ensures that cleanliness and a sense of well-being is sustained by virtue of its association with worship. The worth and significance of wudhu is not limited to the medical benefits discussed here. However, for anyone else wondering why taking a pause on a busy day with wudhu feels so rejuvenating, I hope this humble article sheds some light to a grand prescription from among the many medicines revealed in the Qur’an.

Our hands are vital for performing tasks throughout our daily lives and must be taken care of and cleaned regularly. They can easily spread germs, bacteria, or viruses such as Covid-19 (Coronavirus). Coronavirus has spread rapidly throughout the entire world in the past few months and health officials are very adamant that hand hygiene can help prevent further escalation of the virus. The reason is simple; viruses can spread from our hands to other objects that we touch, to which other people can touch those same objects and possibly contract the virus by putting their hands on their face. According to the World Health Organization, proper hand sanitation that uses alcohol-based rub or hot water and soap can kill Coronavirus and other viruses [1].

For some people, such as healthcare professionals, there are actually major consequences for neglecting hand hygiene. For example, the dirty hands of these professionals have a negative impact of 40% in the transport and spread of resistant microorganisms among patients. Hospital infections are actually among one of the main catalysts for increased disability and death rates in hospitals, along with additional healthcare costs [2]. In the United States, 1.7 million patients develop health-related infections every year, and 100,000 of them die. This increases the length of hospital stay by 20 times and the cost of treatment by 5 times [3].

It was not until the 19^th century that we began to understand that infectious diseases can be prevented by washing our hands. In the middle of the same century, the pioneer of antiseptic processes, known as the “savior of mothers,” Hungarian physician Ignaz Semmelweis, showed that microorganisms could be transmitted to patients via the hands of medical staff. This discovery began a new era of hygiene and healthcare. It is now well known that microbes reproduce rapidly, and that it is possible to prevent the spread of disease by keeping the hands and body, which is possible by following personal hygiene rules.

Hand hygiene is maintained in different ways in modern medicine. In daily life, washing hands with soap and water to remove dirt is called “social hand washing.” Common examples include washing after a meal and when visiting the toilet. For this purpose, it is sufficient to rub the hands and fingers for 15 seconds with a non-antimicrobial feature soap, rinse, dry with a disposable towel, and turn off the tap with a towel. Cloth towels used by many people in public places are not considered suitable for hygiene.

The more serious and professional form of hand washing is “hygienic hand washing,” where antimicrobial soaps are used in the washing process before and after contact with patients and bodily fluids. Other hand hygiene methods during surgical operations cover applications where alcohol-based 3-5 ml hand-disinfectant is rubbed until dry along with hand disinfection and surgical hand antisepsis, which includes washing the hands, including the forearms, with chemical solutions such as soaps, isopropanol, chlorhexidine specifically produced for this purpose for 2-3 minutes, and later wearing sterile gloves until the end of any procedures.

The World Health Organization published a guide on proper hand hygienics and explained when, how often, and how healthcare providers should wash their hands [4]. Despite the development of various programs and policies, especially hand hygiene, and increasing material expenditures in the fight against infections observed in health services, the control of infections remains well below the desired level.

Today, research also looks at the effects of hand washing on individual psychology. An experiment carried out by two psychologists from the University of Michigan, Spike W.S. Lee and Norbert Schwarz, shows that hand-washing reduces this classic post-decisional dissonance effect:

In individual sessions, 40 undergraduates browsed 30 CD covers as part of an alleged consumer survey as if they were in a music store. They selected 10 CDs they would like to own and ranked them by preference. Later, the experimenter offered them a choice between their 5th and 6th ranked CDs as a token of appreciation from the sponsor. Following the choice, participants completed an ostensibly unrelated product survey that asked for evaluations of a liquid soap; half merely examined the bottle before answering, whereas others tested the soap by washing their hands. After a filler task, participants ranked the 10 CDs again, allegedly because the sponsor wanted to know what people think about the CDs after leaving the store.

For those who merely examined the soap, the preference for the chosen over the rejected alternative increased from before choice to after choice by an average of 1.9 ranks, replicating the standard dissonance effect. In contrast, for those who washed their hands, preferences were unaffected by their decision. Thus, handwashing significantly reduced the need to justify one’s choice by increasing the perceived difference between alternatives. “Washing one’s hands after making a choice eliminates post-decisional dissonance effects, suggesting that hand-washing psychologically removes traces of the past, including concerns about past decisions” [5].

In another study conducted in 2008, Schnall, et. Al. “hypothesized that physical cleanliness reduces the severity of moral judgments. In support of this idea, they found that individuals make less severe judgments when they are primed with the concept of cleanliness and when they wash their hands after experiencing disgust” [6]. This effect of hand washing, which relieves conscience, is called the “Macbeth Effect.”

Washing hands is one of those simple but compulsory practices we tend to take for granted and lose interest in as we progress in science and education. Simple practices like using each of our hands for different purposes and frequent hand-washing will surely contribute to the fight against healthcare infections and infectious diseases that threaten public health.

There are several traditions of Prophet Muhammad, peace be upon him, in which washing hands is strongly emphasized.

“The blessings of food lie in washing hands before and after eating.”

“Wash your hands after you wake up; you do not know where your hands have moved while you were sleeping.”

The Prophet advised using each hand for different tasks. It is narrated that his wife Aisha said: “The right hand of the Messenger of God (peace be upon him) was for his purification and food, and his left hand was for using the restroom and anything that was dirty.”

Notes

1. “Advice for Public.” World Health Organization, World Health Organization, www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public.
2. Pittet D, Allegranzi B, Storr J, Donaldson L. Clean care is safer care: the global patient safety challenge 2005-2006. Int J Infect Dis. 2006; 10(6): 419–24.
3. Allegranzi B, Storr J, Dziekan G, Leotsakos A, Donaldson L, Pittet D. The first global patient safety challenge “Clean care is safer care”: from launch to current progress and achievements. J Hosp Infect. 2007; 65(Suppl. 2): 115–23.
4. WHO Guidelines on Hand Hygiene in Health Care, www.who.int/gpsc/5may/tools/9789241597906/en/
5. Lee SW, Schwarz N. Washing away postdecisional dissonance. Science. 2010 May 7;328(5979):709. doi: 10.1126/science.1186799.
6. Schnall S, Benton J, Harvey S. With a clean conscience: cleanliness reduces the severity of moral judgments. Psychol Sci. 2008 Dec;19(12):1219-22. doi: 10.1111/j.1467-9280.2008.02227.x. Also see https://psycnet.apa.org/fulltext/2014-20922-011.html in which Johnson, D. J. et. al. suggest that “researchers investigating the connections between cleanliness and morality should therefore use large sample sizes to have the necessary power to detect subtle effects.”

We all may appreciate the difference between the positive impact made by a smile of pearly-white teeth and the repulsion triggered by yellowed and blackened rotten teeth, but the health issues run much deeper: as our medical knowledge grows, we are discovering that many diseases originate from dental cavities where microbes teem and nest, causing inflammations in many organs and tissues, most notably in the heart, kidneys, and joints.

The use of herbal sticks for cleaning teeth dates back to around 3500 BC, the time of the Babylonians. In several works of Ancient Greek and Roman literature, chewable sticks to aid dental and mouth hygiene are mentioned [1]. Hippocrates (355 BC) advises rubbing a ball of cotton wrapped around a stick and dipped in honey on teeth, to maintain dental hygiene, whereas Romans used pastes obtained from gumwood [2]. Dental hygiene is coming throughout history.

Arabs utilized the miswak for many years [3]. The Japanese used wooden sticks called “koyoji” and Jews used wooden sticks called “kesam.” In the 1920s, in some rural areas across the United States, a stick of blood-twig was used for rubbing on the teeth [3]. And according to a Chinese encyclopedia published in the seventeenth century, the first-ever toothbrush was made in China, in 1498.

Prophet Muhammad, peace be upon him, warned those of his Companions who visited him with bad teeth about the need for dental hygiene (Ahmad ibn Hanbal, Musnad 1/214):

“I oft reiterated my recommendations to you about the miswak.” (Bukhari, Jum’a 8; Nasai, Taharah 5; Ahmad ibn Hanbal, Musnad 3/143; Darimi, Wudhu’ 18)

“(The Archangel) Gabriel counseled me to use the miswak so much that I thought a verse might be revealed about the miswak to decree its use as obligatory for all.” (Ibn Majah)

Obviously he assigned the utmost importance to dental hygiene. It should be noted here that the Araq tree (Salvadora persica) from which the miswaq is obtained has features that are not present in other trees, and the Prophet particularly specified using the roots of that tree as the miswak.

Research has been conducted to discover the scientific and modern medicinal effects of the miswak, which has been used by Muslims in adherence to the Prophet’s practice. In 2010, a Ph.D. study at Karolinka Institute, Sweden, provided a significant message about its effectiveness [4] (Picture 1).

The Araq tree, which is used as the miswak across a geography spanning from Africa to the far east, is a short tree or bush with a slanted trunk, and it is easy to chew its spongy roots, parts of which generally expand and soften when dipped in water (Picture 2).

The roots of the Araq tree are washed to remove the soil, and approximately 1 cm from the tip of the root stick is peeled to be used as the toothbrush. The stick is pummeled or chewed until the fibers become softer (Picture 3). Fresh and soft miswak are preferable: If the miswak is dry, it is advised to dip it in freshwater for 24 hours before use. It is better to peel frequently, so the tip is renewed. The most practical advice is to use the peeled tip until it loses its tang and fragrance, because the fragrant components indicate the beneficial effect of the miswak. According to a study, using the same tip for more than 24 hours lowers its cytotoxic ability to get rid of microbes.

The practice of using miswak in the Muslim World is widespread in Asia, Africa, and some regions in the Middle East. As many Muslims opt for miswak use to maintain a practice of the Prophet, the World Health Organization (WHO) also advises and encourages the use of miswak as an effective dental hygiene tool along with the conventional toothbrush. The miswak is easy to use and effective; it also has chemical properties that help control dental plaque. Based on the basic information we have about the miswak, we can easily say that deeper research is needed for its different components, like its fibers, essence, and essential oils.

Antibacterial effects of the miswak

The antibacterial activities of the essences obtained by crushing different roots of the miswak have been analyzed by microbiological techniques. It was discovered that the miswak essence has a very strong antibacterial effect, predominantly against Gram-negative bacteria, including mouth-cavity microbes like Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans. Two additional studies conducted on five different types of bacteria i.e. Streptococcus mutans, S. faecalis, S. aureus, Haemophilus influenzae, Salmonella enterica, and Candida albicans, and a type of fungus [5, 6, 7, 8] revealed that the miswak essence stops the reproduction of micro-organisms, has a lower effect on Lactobacillus acidophilus, is active against Herpes simplex virus which causes blistered lesions, and suppresses acid production.

The essential oil obtained from miswak essence includes 70% benzyl isothiocyanate, 9.4% limonene, 8.7% I-pinene and 2.55% flavonoid. As the miswak’s main antibacterial component, benzyl isothiocyanate kills bacteria by forming protrusions on their cell membranes. The volatile nature of this substance may open doors to new practices requiring antibacterial treatment. It has been proven that fresh miswak is effective at preventing the formation of dental plaque and gum inflammation, and it has also been acknowledged that it may play a potential role in preventing periodontal diseases.

The miswak essence hinders acidic (pH) conditions causing tartar and dental plaque, leads to a long-term increase of pH in the mouth, stimulates saliva flow in the parotid glands (located in front of both ears), and prevents tartar formation.

It is necessary to conduct further lab and clinical research to augment the positive results shown so far about the effects of the miswak against the inflammation of the palate and gums, as well as its antiviral and antifungal activities. Some research has additionally suggested that the miswak has antioxidant, analgesic, and anti-inflammatory effects. It is claimed that potassium chloride, salvadourea (a urea derivative), alkaloids, and oleic and linoleic acids in the miswak sap increase the viscosity of saliva, helps it to soak into hard-to-reach corners in the mouth, and contributes to overall dental hygiene. It is reported that a substance named Xylitol in the miswak essence suppresses acid production and the reproduction of mutant streptococci [9, 10].

An interesting substance in the miswak oil

Benzyl-isothiocyanates are effective molecules in the defense systems of several plants such as cabbage, watercress, and broccoli. Secreted after damage to plant tissues, benzyl isothiocyanate forms a protective antibacterial layer on the damaged part of the plant. While dental plaque and tartar are mechanically removed by rubbing the miswak on teeth, this action also helps the substance secreted from the miswak reach deeper parts of the oral cavity. It is especially proven that benzyl isothiocyanates are strongly effective as bactericide on Gram-negative bacteria and have minimal effect on Gram-positives.

Lab tests conducted on animals indicate that these components also have anti-carcinogenic activity, and people who get isothiocyanates by nutrition have a lower risk of cancer. It is fascinating that the miswak, too, has the same substance.

While introducing a new set of ethical principles, Prophet Muhammad, peace be upon him, revoked some customs and habits inherent to the pagan culture before Islam (Age of Ignorance) and kept others. Using miswak was a practice among the Arabs in the region; the Prophet encouraged its use and emphasized its benefits. Eventually, Muslims have adopted it as not only a habitual practice, but also as a healthy spiritual activity and are keeping the memory of the Prophet alive.

References

1. Wu, C.D., Darout, I.A. and Skaug, N. (2001): Chewing sticks: timeless natural toothbrushes for oral cleansing. Journal of Periodontal Research 36, 275-84.
2. Hyson, J.M., Jr. (2003): History of the toothbrush. Journal of the History of Dentistry 51, 73-80.
3. Bos, G. (1993): The Miswak, an aspect of dental care in Islam. Medical History, 37, 68-79.
4. Sofrata, A. H. (2010): Salvadora persica (Miswak). An effective way of killing oral pathogens. Thesis for doctoral degree (Ph.D.). From the Division of Periodontology, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.
5. Al-Lafi, T. and Ababneh, H. (1995): The effect of the extract of the Miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria. International Dental Journal, 45, 218-222.
6. Almas, K., Al-Bagieh, N. And Akpata, E. (1997): In vitro antimicrobial effect of extracts of freshly cut and 1-month-old miswak (chewing sticks). Biomedical Letters, 56, 145-149.
7. Almas, K. (1999): The antimicrobial effects of extracts of Azadirachta indica (Neem) and Salvadore persica (Arak) chewing sticks. Indian Journal of Dental Research, 10, 23-26.
8. Almas, K. (2001): The antimicrobial effects of seven different types of Asian chewing sticks. Odontostomatolgie Tropicale, 24, 17-20.
9. Kakuta, H., Iwami, Y., Mayanagi, H. and Takahashi, N. (2003): Xylitol inhibition of acid production and growth of mutans Streptococci in the presence of various dietary sugars under strictly anaerobic conditions. Caries Research, 37, 404-409.
10. Miyasawa, H., Iwami, Y., Mayanagi, H. and Takahashi, N. (2003): Xylitol inhibition of anaerobic acid production by Streptococcus mutans at various pH levels. Oral Microbiology and Immunology, 18, 215-219.