The old dictum, Cleanliness is next to godliness, attributed to the theologian and philosopher Saint Thomas of Aquinas may ring hollow in the ears of many in the world today, to whom access to appropriate sanitation and safe drinking water is denied. During St Thomas’ lifetime, about 800 years ago, godliness was the highest moral virtue to which believers aspired; and cleanliness of the body and the spirit was next. In this day and age of globalization however, where some highly educated, trained and skilled physicians reportedly still do not bother to wash their hands after touching one infected wound or contaminated object, before they go to touch the next patient; it seems hard to decide whether cleanliness is a virtue or a vice, or both; and where it sits in relation to godliness, or whatever has replaced godliness. There are “global giants”, multinational companies such as Unilever, who have amassed excessive amounts of wealth by means of highly skilled and successful social marketing of soap and other detergents for domestic use in both rich and poor countries1 , ethically. What once seemed to be a simple act of washing hands with water and soap to remove dirt now seems no less complicated and worthwhile than the art and science of heart surgery, at least in terms of getting it absolutely right – without killing the patient. The only difference might be that a doctor will take pride in her/his surgical competence and want to show off, but not feel the same way about mastering the art of washing hands with soap, rubbing between fingers and scrubbing nails to remove all traces of contamination in the course of her/his daily ward round. This volume brings home to the reader some of the subtle and intractable issues facing African health care systems, health workers, hospital patients, and people in the community today. Specifically, three research papers focus on hygiene practices in Keren hospital, Eritrea (Samuel et al.,) set in the wider context of prevention and control of hospital acquired infections (HAI), otherwise known as nosocomial infections internationally; adoption of improved sanitation-related hygiene practices in the Eastern Cape Province of South Africa (Nuntsu et al.,), and drinking (spring) water quality in two parishes of Kampala, Uganda (Haruna et al.,). Hygiene, a term which derives from the ancient Greek word for health, is often neglected by those who should care about it most. Government health budgets seldom have hygiene promotion near the top of their lists. An original contribution from Eritrea highlights the need for hospitals to take seriously the question of setting local standards for infection prevention. The Keren study is thought provoking to everyone involved in health service provision in Africa and indeed elsewhere. Individual commitment to prevent and control the spread of infections that are literally carried by hand from one person to the next is at the heart of the matter. It may be surprising for readers in Africa to learn that lack of access to water and soap is not necessarily why health workers fail to wash their hands in hospitals in rich countries in Europe and North America. Samuel et al., insist, however, that this should not be a cause for complacency. If highly educated and skilled physicians do not take the trouble to practice what they know to be ‘godly’ – i.e., to help restore their patients’ health and not to make it deteriorate by introducing deadly pathogens – community efforts to encourage and facilitate the adoption of hygienic practices will not succeed. Their message is that we should all ‘connect the dots’ between home and hospital or health station and back, and do our best to wash our hands off the crime of pathogen trafficking. If what is at issue is poverty, the root of all evil; and if it is greed that begets and maintains riches, the only means to cleanliness, then cleanliness is very close to greed, and very far from godliness. Then it must be greed that has taken the place of godliness. Would we be justified to modify the proverb to ‘cleanliness is next to greed’ then? Wouldn’t this turn cleanliness into a vice, the highest (or the lowest, depending on which way we look at it) of which is greed? Is it not greed that has taken the place of godliness in today’s world? But there is also much conspicuous charity around us, witness the massive outpouring of donations to help victims of the Tsunami disaster. Admittedly, it takes a disaster to galvanize humanitarian action. Nuntsu et al.’s study makes this point: it is only when a cholera epidemic strikes that local institutions come to do something about inadequate sanitation. Shouldn’t sanitation services for the majority in South Africa be provided by way of restoration of social equity and basic human rights? What is inhibiting progress on this front, now that apartheid is no more? Is cleanliness a virtue only the rich will continue to afford? Will the ability to adopt hygienic practices remain ‘pie in the sky’ for the majority of African children and women and men this century, already afflicted with incurable disease such as HIV-AIDS and Tuberculosis? Shouldn’t the millennium development goals tackle greed directly? Unhygienic practices affect quality of life, and quality of health care can spell life or death for South Africans. The evaluation of quality of spring water in Kampala, a natural resource threatened by contamination from inadequate sanitation services concludes by prescribing treatment of drinking water, which brings us back to the question: is cleanliness a vice or a virtue, or both?