The Coronavirus Killed the Handshake and the Hug. What Will Replace Them?

Dr. Mark Sklansky has always hated shaking hands. He can think of about a dozen better ways to greet patients than the icky exchange. “Hands are warm, they’re wet, and we know that they transmit disease very well,” says Sklansky, chief of pediatric cardiology at UCLA Mattel Children’s Hospital. “They’re a phenomenal vector for disease.” He’s also tried to avoid this form of greeting because he knows that some patients don’t want to shake hands for religious or cultural reasons but feel compelled to when their doctor sticks out a hand. For a long time, though, being anti-handshake was fringe thinking. The handshake is such an ingrained part of the doctor-patient relationship that it happens 83% of the time, according to one 2007 analysis of more than 100 videotaped office visits.

Sklansky was once nervous to take a stand against the popular gesture. “I honestly didn’t want to admit this to anyone for the longest time,” he says. But in a 2014 paper, Sklansky and his colleagues argued that shaking hands in health care settings can spread pathogens and viruses, and that health care workers can help keep patients safe by keeping their hands to themselves.

The blowback was swift. Physicians huffed that getting rid of the handshake would erode the already fragile doctor-patient bond, that the greeting was irreplaceable, and that they could manage to shake hands and wash them without spreading disease, thank you very much. “A lot of people laughed at the idea,” Sklansky says. “But now, people aren’t laughing.”

Handshakes are just one form of touch that has evaporated during the global coronavirus outbreak. So have hugs, high fives, fist bumps, back pats, shoulder squeezes and all of the little points of contact we make when we stand closer than six feet apart. And as Americans emerge from their homes and inch closer together to rebuild their social lives, experts are betting that some degree of social touch will disappear permanently, even after the pandemic ends. “I don’t think we should ever shake hands ever again, to be honest with you,” said Dr. Anthony Fauci in an April interview with the Wall Street Journal podcast.

If social touch disappears more than just temporarily, there’s no consensus on what will replace it. But one thing is little disputed: Social interactions are about to start feeling really weird.

“As we come out of quarantine and isolation, I think we’re going to see some people offering handshakes and some people not wanting to touch them with a 10-foot pole,” says Aaron Smith, a psychotherapist and instructor in the school of social work at Renison University College in Canada who explored the pluses and pitfalls of handshakes in a journal article published in March. “There’s going to be a lot of awkwardness as people try to figure out how to greet somebody, how to professionally welcome somebody, how to meet your daughter’s boyfriend for the first time.” This uncertainty can affect those relationships. “We’re going to start seeing a lot more interpersonal and family-based sorts of conflict,” Smith predicts. If a business colleague attempts a handshake or your mom goes in for the hug, and you pull away, “there’s going to be some pretty big ripple effects in terms of the relational dynamics that we see.”

Why we touch

Even if you hate being hugged outside of intimate relationships or despise shaking hands, losing social touch completely—as we have during COVID-19—still may not feel normal. “Suddenly, we’re starting to realize all of these touches that are missing,” says Juulia Suvilehto, a researcher at Linköping University in Sweden who studies social bonds. “It feels like there’s this weird gap.”

Touching acquaintances and strangers serves an evolutionary purpose. Language is the most obvious way that humans foster social ties with one another, but touch does something similar. “We know that nonhuman primates use social touch a lot through grooming,” Suvilehto says. “The larger the group, the more time they spend on it. It’s a way of making allies and maintaining relationships.” Touch also helps reduce aggression between people, says Tiffany Field, director of the Touch Research Institute at the University of Miami School of Medicine. “When you’re socially touching someone, it’s very hard to be aggressive towards them.” Conversely, “if you separate two monkeys and they can see, hear and smell each other, but they can’t touch each other, once you remove the plexiglass, they practically kill each other.”

Over her career, Field says she has watched touch fall off so sharply in American society that she thinks she’ll have to find something else to study. Social hugging was largely sidelined by the Me Too movement, and smartphones took care of the rest. About a year ago, she and her students observed people as they sat at airport departure gates and recorded how often they touched one another. She expected to see people holding hands with their intimate travel companions and slinging their arms around each other. “We weren’t seeing any touching, even between couples and families who were traveling together,” Field says. “Everyone was on cell phones…just scrolling and texting and gaming.”

Field doesn’t think touch will bounce back socially—she suspects the elbow bump will edge out the handshake—but she’s hoping that touch is returning among families who are spending more time together in quarantine. Welcome touch is good for your health; it’s been shown to lower stress and activate the release of oxytocin, which is nicknamed the “love hormone” and helps promote bonding and closeness.

Nice to meet you?

Shaking hands is probably the most common form of social touch in the U.S., and it’s thought to have originated many centuries ago as assurance that neither party was carrying a weapon. “It signals trust and cooperation,” says Sanda Dolcos, who runs a neuroscience research lab at the University of Illinois with her husband, Florin Dolcos. In the team’s neuroimaging studies, “you can really see in the brain that areas that are involved in processing rewards are activated when people are shaking hands,” Sanda says. Even watching people shake hands is enough to increase activation in the brain’s reward centers, their research has shown.

“The expectations that come in terms of social or physical interactions are so hardwired,” Florin says, that he doesn’t expect the handshake to permanently disappear after the pandemic is under control. Neither does Smith. “I would be stunned if a year from now, it was gone,” Smith says. “I would be absolutely shocked because of how commonplace and universal it is. I don’t see it going away overnight.”

But even they believe that it will change. People might reserve handshakes and hugs for those who are closest to them and who they trust the most and develop new greetings that don’t involve skin-on-skin contact for those further outside their social circle. There are many alternatives: the elbow bump, a foot tap, a bow, the namaste gesture, a brief nod or head tilt, placing a hand on your heart. It’s unclear which of these will prevail, if any. “You see such a wide range of values and beliefs and political views about all of this stuff,” Smith says. “Underlying all of those are layer upon layer of professional and personal beliefs and values stemming from our childhood, from our religious orientation, from the messages we’ve been taught in school.” We won’t all arrive at the same solution.

But research has shown it is possible—to some degree—to embrace touch-free alternatives. Sklansky, the pediatric cardiologist and anti-handshake crusader, conducted an experiment to see if he could eradicate the handshake in two of UCLA’s neonatal intensive care units, where some of the most vulnerable patients are treated. In a 2017 study, he describes setting up handshake-free zones by posting signs depicting two clasping hands, crossed-out, and encouraging the doctors, nurses and residents to try different nonverbal greetings. While about a third of providers were resistant—especially physicians, and especially men—nearly all of the patient families were in favor of not being touched by their doctor. Fewer than 10% said they wanted to be greeted with a handshake. The vast majority preferred instead when health care providers looked them in the eye, smiled, addressed them by name or asked about their wellbeing.

The handshake has long been a way for doctors to quickly establish rapport with their patients, but something contactless is now necessary—not only because of the pandemic, but also because of the rise of telemedicine. “We’re not going to have some sort of digital handshake,” says Gregory Makoul, founder and CEO of PatientWisdom, a company that helps health organizations improve patient engagement and communication. Makoul co-authored the 2007 study about how prevalent handshakes are in health care, but he believes that words can also build a bond. “You need to have the kind of conversation that makes that connection.”

The future of social touch is here

If you feel that personal connections are harder to form when talking to someone six feet away or through a screen on Zoom, you’re not alone. “You’re having to verbalize a lot more things that you would normally express with touch,” Suvilehto says. Hugging someone who needs comforting or placing a hand on their shoulder often feels easier and more natural than finding the right words.

Being forced to voice these feelings might turn us into better communicators. “But the other option is that people will just stop communicating about emotions,” Suvilehto says.

Just as social touch can be a substitute for language, you may have to over-communicate with words the feelings you would once get across through physical contact. Welcome to Sklansky’s world, who’s been taking the long, verbose way around the handshake for years. “When people reach out, I just say, ‘Listen, I’d rather not shake hands. I don’t think it’s a good idea for different reasons.’ I explain why, and I talk about the paper,” he says. He opts instead for the namaste gesture. “People smile and think it’s sort of funny,” he says. “But I think it’s something that over time, people could get used to here.”