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Covid-19’s big public health lesson: Ask people to be careful, not perfect

Harm reduction works. Covid-19 has proved it.

People sit in prescribed circles at a New York City park.
People gather at a New York City park on July 26, 2020.
Alexi Rosenfeld/Getty Images

For too long, America has approached public health issues with puritanical, black-and-white approaches. Whether it’s an abstinence-only approach for teen sex and HIV/AIDS, or refusing to provide clean needles and overdose antidotes to people who use drugs, the country has a tendency to prefer the perfect but unrealistic over the better and pragmatic. The US repeated those mistakes again with the Covid-19 pandemic.

Much of the discussion about the coronavirus and how to mitigate it has been framed in absolutist terms. The initial phase of the pandemic was marked by harsh lockdowns, including relatively safe spaces like parks and beaches. People created Instagram accounts to shame those who didn’t perfectly follow the precautions. Schools have remained closed partly because parents and teachers are worried about any risk of Covid-19, suggesting that any risk whatsoever is too much.

But over the course of the pandemic, an alternative has started to take hold: harm reduction. The approach, initially popularized by activists working on drug use and HIV/AIDS, focuses on minimizing risk, even under less-than-ideal circumstances, such as telling people to have safe sex rather than abstain entirely, or be monogamous to avoid HIV. In theory, it’s not the best approach for preventing HIV, but it’s better, while letting people live their lives closer to what they want.

Over the past year, people have started to take approaches that enable them to do the things they love — even if that means minimizing risk rather than eliminating it entirely. Now, more people are dining out and going to parks, mitigating the risks involved with social distancing and masks. Federal officials have pushed to reopen K-12 schools, talking about reducing risk rather than completely eliminating it.

Many of the experts I’ve talked to throughout the course of the pandemic have certainly become more receptive to harm reduction since Covid-19 first emerged.

“You can’t just tell people to stay home” — that clearly hasn’t worked, Saskia Popescu, an infectious disease epidemiologist at George Mason University, told me. The right approach, she argued, tells people, “If you have to leave your house, here’s a way to understand risk and the spectrum of risk, and here’s how to protect yourself.”

But, experts say, the transition to a greater embrace of harm reduction has taken too long in the US and there are still pockets of resistance, not just among the public and politicians but even some experts, too. During the vaccine rollout, for example, news articles and experts have warned about people gathering after they get vaccinated because there’s still some risk that a vaccinated person could carry and spread the virus.

“There’s a very large streak of abstinence-only — even in my own field,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me. “The evidence is incontrovertible on harm reduction. My problem with harm reduction is we didn’t go far enough.”

The consequences of this are hard to precisely measure, but experts say the resistance to harm reduction has likely caused unnecessary suffering and deaths. The initial resistance to reopening parks and beaches robbed people of a relatively safe avenue to relax during a very stressful lockdown period, making them more likely to become fatigued and resistant to Covid-19 precautions.

The school closures, even as evidence has shown in-person teaching can be made fairly safe, have resulted in huge learning gaps and mental health problems for students. And it’s left parents reliant on school services, from supervisory functions to lunches, struggling to make ends meet.

Suggesting you won’t even be able to hug your vaccinated loved ones after you get a vaccine could lead some people, particularly those already skeptical, to ask why they should bother — right as we need just about everyone to get a shot.

Harm reduction has long offered an alternative approach. But the US still hasn’t fully embraced it.

Harm reduction, briefly explained

Harm reduction is about not letting perfection be the enemy of the good.

“Adults make trade-offs all the time,” Ashish Jha, dean of the Brown University School of Public Health, told me. “Zero Covid is just not a choice for a lot of people. So we’ve got to give people better options.”

There are lots of things that you might believe people shouldn’t do: Teenagers shouldn’t have sex. People shouldn’t have multiple sex partners. People shouldn’t use drugs. People shouldn’t gather with friends and family while a virus is spreading among the population.

Harm reduction acknowledges people are going to do all of these things anyway, no matter how much you tell them it’s not good for them. The idea, then, is to take a more pragmatic approach and ask how all of these things can be made as safe as possible — to mitigate, even if not fully eliminate, the risk that someone ends up hurt.

So maybe you’d prefer if your teenaged kids weren’t having sex, but you give them access to birth control because you know they will anyway. Maybe you think your brother should really stop using heroin, but at least you can give him access to sterile syringes to reduce the risk he shares or reuses needles and gets an infection. Maybe you know you shouldn’t go to the gym, but you’re willing to accept the risk as long as you can mitigate some of it if you wear a mask, use hand sanitizer, and keep 6 feet away from other people.

In the real world, the evidence suggests this works. One example: needle exchanges, where people can obtain clean syringes to inject drugs. Studies from independent researchers, the World Health Organization, and the Centers for Disease Control and Prevention have concluded there’s no evidence that needle exchanges lead to more drug use. Instead, the studies found exchanges reduce the spread of diseases that can infect people through injection drug use (like HIV and hepatitis C) and help connect people to addiction treatment.

It’s not that the people advocating for this approach want others to use drugs. To the contrary, as I’ve visited needle exchanges while reporting on the opioid epidemic, the programs’ staff have consistently echoed the same message: They’d prefer their clients don’t use drugs, but the program will keep them alive as long as needed, hopefully until they finally decide to quit. In fact, needle exchanges often work with addiction treatment providers to connect their clients to care when they’re ready — some programs even offer treatment on-site.

It’s the same with an array of issues. From sex education to HIV prevention to masks, the harm reduction approach often comes out on top.

“The US in particular struggles with making a distinction between individuals’ roles and … what’s society’s responsibility — and not easily recognizing that a lot of individual choices and behaviors are dictated by structural and societal factors,” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told me, pointing to people’s jobs and family responsibilities. “There’s going to be a lot of factors that prevent people from taking the ideal steps in a public health context. You want to recognize what those factors are and minimize the harm to them and to others.”

Covid-19 has more clearly brought these concepts from largely marginalized populations, like people who use drugs and those at risk for HIV, to the rest of the country.

The US has a bad history with resisting harm reduction

Despite the evidence for harm reduction interventions, the US and many leaders have often resisted such policies, typically on puritanical grounds.

In 2015, Indiana suffered from an HIV epidemic linked to the injection use of Opana, a prescription painkiller that’s been widely misused throughout the opioid crisis. But then-Gov. Mike Pence and other lawmakers opposed needle exchanges. It wasn’t until the HIV epidemic worsened that Pence and others relented, allowing the programs on a limited basis.

Even then, some Indiana counties continued to oppose needle exchanges. In 2017, Lawrence County commissioners shut down the local needle exchange program. Their reasoning was not the evidence — since, after all, there are decades of studies backing needle exchanges. Instead, county Commissioner Rodney Fish cited the Bible and claimed, “I did not approach this decision lightly. I gave it a great deal of thought and prayer. My conclusion was that I could not support this program and be true to my principles and my beliefs.”

This is typical. Much of the country would simply prefer that people not use drugs. Because needle exchanges are seen as enabling drug use — by making it safer — they oppose the programs. To date, the federal government prohibits funds from going toward syringes at needle exchanges (though that’s an improvement from previous decades, when federal funds couldn’t go toward needle exchanges at all). In these cases, the perfect turns into the enemy of the good.

Over the past year, social media accounts have cropped up explicitly to shame people for not following Covid-19 precautions, particularly social distancing and mask-wearing. Flocks of social media users have joined in, posting and mocking photos of people going out to parties or gatherings and not wearing masks.

But moralizing and shaming don’t work. In fact, they can do the opposite, as people instead go underground to hide their supposed misbehavior, now resentful of those shaming them and, in that resentment, perhaps less willing to adhere to recommended public health precautions.

A harm reduction approach would instead try to guide people to safer activities and behavior. Maybe it would take the form of advising them on mask use. Or push them to safer settings: perhaps outside, with fewer people, or a “pod” in which a group of people agrees to limit contact with others outside the group. This could still acknowledge that the current behavior is unsafe, but offer strategies for risk reduction instead of pure shaming.

A related problem has permeated America’s vaccination efforts. As the vaccines have been rolled out, several articles and experts have argued that getting vaccinated doesn’t mean you can live your life a little closer to the pre-pandemic normal. One headline claimed that “COVID-19 vaccine doesn’t mean you can party like it’s 1999.” Other articles argued that the vaccinated should still stay away from each other and, if they’re close, wear masks.

It’s true we still don’t know just how much vaccines stop the spread of Covid-19, with the clinical trials only showing that the vaccines protect the inoculated from the virus. New research may confirm just how much the vaccines stop transmission, though so far the early evidence is very positive.

But this kind of messaging, experts warn, can serve to make people wonder why they should get vaccinated at all. Especially as America gets its vaccine supply issues under control and vaccine hesitancy becomes the bigger problem, that’s the wrong message to send. Already, surveys show around 30 percent of people are vaccine-hesitant. Driving that up higher gets us even further from the prospect of herd immunity (when enough of the population is vaccinated to stop the spread of the virus), which experts estimate could require as much as 80 or 90 percent of people to be vaccinated.

Embrace what works

One way to address all of this: The country could discard the binary language of “safe” and “unsafe” and instead approach risks and harms more like a spectrum.

“You see people falling into false alternatives — that it’s Mardi Gras 24/7 or that it’s Wuhan 24/7,” Adalja said. “It’s actually not either of them.”

Here’s an example, from a previous Vox article, that holds up:

A table showing how different places present different levels of risk during the Covid-19 pandemic: Your home is the safest place. Outdoor environments present moderate and higher risk. Indoor spaces with people you don’t live with present the highest risk. Amanda Northrop/Vox

The idea behind this graphic isn’t to tell people they can’t do one of these things. Instead, it presents the different levels of risks for each activity and advises on how to mitigate that risk. People can then take the risk levels, the advice, and their own personal conditions — what risk level they’re comfortable with, what the benefits of the activity are, whether they’re vaccinated, whether they’re in a pod with the people they’re interacting with, and so on — and act accordingly.

It’s still true that indoor gatherings are the riskiest setting for Covid-19 spread. But there are still situations where indoor gatherings are totally understandable: Grocery stores are necessary so people can eat. Hospitals provide life-saving care. Schools help both parents and students. Given the benefits of these places, the better choice is to mitigate risk instead of shutting all these places down to eliminate risk entirely.

It’s not about whether grocery stores, hospitals, or schools are fully “safe”; it’s about weighing the pros and cons, and trying to maximize the pros while limiting the cons.

In many ways, we have done that throughout the pandemic. Grocery stores and hospitals didn’t close down, after all.

But that has not always been the case. Even as more research has shown that in-person teaching can be made much safer with proper precautions, policymakers, school staff, and parents have been slow to support those measures, and in some cases resisted reopening schools at all. Much of the debate around schools is still centered around whether schools are “safe,” rather than acknowledging the risks, but also the benefits, and working to mitigate the risks to still get the benefits.

This kind of thinking has hurt parents and students. And it’s led to suffering and mistakes in other areas, from recreational activities to the vaccine rollout.

It’s also potentially a key reason that so many Americans simply gave up on precautions like social distancing and masking as the pandemic dragged on because, well, why bother with mitigation if everything is supposedly so dangerous anyway?

In simulations experts ran before the pandemic, some experts could see this kind of failure coming. “Through every single exercise I’ve done, in the hotwash is always communication failures — every single time,” Popescu said, arguing that a commitment to developing better messaging around harm reduction and science in general could help.

The pandemic has created an opportunity for America to see, up close and personal, the virtues of harm reduction and embrace them — if not in time for the current public health crisis, then perhaps at least for the next.

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