In the wake of the omicron surge, governments around the world are reassessing their COVID-19 strategy. The risks have changed. Now, policy needs to shift, but it also needs to be anchored in a public health approach that keeps people safe as society reopens.
That strategy is called harm reduction.
Harm reduction “abolishes the all-or-nothing approach to risk and disease,” write doctors Eric Kutscher and Richard Greene in an article published in the Journal of the American Medical Association. Human well-being depends on many factors, economic, social and psychological, as well as medical. Harm reduction accepts that reality and “puts public health policy in the context of life,” according to Monica Gandhi, an infectious-disease specialist at the University of California, San Francisco.
I learned the core tenets of harm reduction in the 1990s, when I worked at a drug policy think tank. At the time, harm reduction was an emergent strategy coming from the streets, with injection drug users devising illegal needle exchanges to slow the spread of HIV/AIDS. Since then, harm reduction has gained legitimacy as a highly effective public health strategy.
For the past 18 months, I’ve been concerned — even angered — that harm-reduction principles haven’t been applied in the fight against COVID-19. But it’s not too late.
As society reopens, dangers remain: long COVID, increased rates of heart attack and stroke after infection, hospitals at or near capacity, with severe cases possible especially among the unvaccinated. Harm reduction can guide us through these risks while returning vitality to society that’s been so sapped of life. Here’s how.
“Everyone right now is struggling to figure out: ‘How can I be with my loved ones, and not put them at risk?’” Greene says. “But there’s no ‘not putting them at risk.’ There’s making good choices. There’s getting vaccinated, wearing masks, getting tested – but there’s not ‘no risk.’ And we have to figure out how to live with that.”
This is perhaps the most basic idea of harm reduction: learning to live with risk.
Policymakers and public health practitioners need to accept that people will engage in risky activities. When we make decisions affecting our health, we take many factors into consideration, economics, core values, pleasure. Some of these decisions draw us toward behaviors that increase the possibility of contracting or spreading disease.
Kutscher makes a parallel to HIV: The COVID-era message to abstain from socializing started to feel like the 1980s, he says, when gay men were “told to be abstinent from sex, ignoring their basic human needs.”
Pivoting to a harm-reduction approach would change the landscape of work, school and leisure, but it would rely on strategies already well-developed. Those strategies are probably known to readers of The Dallas Morning News, and fall into four broad categories:
- Savvy use of testing, including wastewater surveillance to detect outbreaks, rapid tests to minimize risk while allowing people to gather, PCR tests for those who could benefit from antiviral treatments.
- Prevention of airborne infection through masks, ventilation and improved filtration.
- A concerted effort to protect the most vulnerable, including the elderly immunosuppressed and people affected by the social determinants of health.
- Continued engagement with communities to increase trust in public-health interventions, including vaccines.
These harm-reduction strategies have been discussed for months. What hasn’t been stated is the harm-reduction framework for thinking about COVID-19. This is a problem, because policy is rudderless without a theory to guide it. By gathering the strategies under the term “harm reduction,” all of us, governments, individuals and businesses, can more effectively coordinate efforts and make decisions that protect us and others, even as we revitalize society.
It’s happening already, but not consistently and not at scale.
One place where harm reduction has worked is St. Louis, through the PrepareSTL initiative. The program brought doctors and public-health practitioners together with community “ambassadors” in a collaborative effort to slow the spread of COVID among immigrants and people of color, says Angela Brown, chief executive of the St. Louis Regional Health Commission, a partner in the project.
PrepareSTL, which started within a week of nationwide lockdowns in March 2020, took the strategy of meeting people where they’re at. This phrase is common in the harm-reduction community. It’s also somewhat vague until seen in practice.
Sometimes PrepareSTL workers literally met people where they were, Brown explains: They distributed masks and COVID-19 information at the places where people gathered, including laundromats, check-cashing stores and senior housing centers. “We knew where to go because members of the community were part of the team,” Brown says.
At a deeper level, PrepareSTL leaders also met people metaphorically, meaning they listened to the concerns, values and emotions of the people they were trying to help, and devised solutions from there. Harm reduction isn’t a strong-arm tactic to muscle a community into accepting an outcome that’s predetermined. It’s about partnership and collaborative problem-solving based on mutual respect. Officials have to understand that the community’s preferred solution might not be the one favored by public-health practitioners.
This discrepancy is often at play with COVID. “The community was adamant that we shouldn’t push the vaccine,” Brown says. “Our message was, ‘The choice is yours – but let it be an informed choice.’”
PrepareSTL officials then provided information, while listening to the community’s questions and underlying frustration with a health care system that’s long disregarded their concerns. In the end, many people decided to get the vaccine, but some didn’t — “and that’s okay,” Brown says. For them, other strategies were hashed out.
In this way, people had ownership of the interventions that pertained to their bodies, livelihoods and lifestyles. That ownership is necessary. Without it, people won’t follow public health guidelines, and that puts everyone at risk — teachers, nurses, doctors, the immunosuppressed.
But harm reduction doesn’t mean that pockets of society refusing the vaccine should be given a green light to do whatever they please. That’s a recipe for poor health outcomes, political fracturing and social rancor. Instead, harm reduction means developing alternative solutions using specific strategies such as testing, masking and ventilation. This is the approach of PrepareSTL. Initial evidence shows it was effective: Rates of racial disparities in COVID-19 infection and fatality were lower in the region covered by the program than in other areas.
Science was supposed to be our savior. New vaccines were supposed to return us to our pre-pandemic lives. With our ultimate faith in science, we lost focus on the basic stuff of public health — building relationships with people.
Harm reduction is the messy, imperfect, ever-changing effort to situate health in people’s realities. And it’s our best way forward, not only for the pandemic, but also for other public health crises faced by this country now and in the future.
Marianne Apostolides is a science writer and award-winning author of seven books. She wrote this column for The Dallas Morning News.
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