In my own field of HIV research, concerns about increases in risky behavior have dogged pre-exposure prophylaxis—PrEP, a pill to prevent HIV—since it was introduced almost a decade ago. The concern is that giving people PrEP will lead to decreased condom use, which could expose them to other sexually transmitted infections and potentially increase the risk of contracting HIV. On these grounds, some clinicians hesitate to prescribe PrEP even though it provides nearly 100 percent protection against HIV—and even when patients are already using condoms inconsistently.
The concern about harm reduction causing riskier behavior has already arisen in the U.S. coronavirus response. It contributed to the dallying in regard to mask recommendations in March and April, with public-health officials worrying that masks would promote riskier social contact by giving people a false sense of security. “We don’t want people to get an artificial sense of protection because they’re behind a mask,” Deborah Birx, the White House’s coronavirus-response coordinator, said early last month. “This worries us.” (The next day, the CDC urged Americans to wear masks in public.)
In all of these examples, a concern about the promotion of risky behavior masquerades as a concern about health. But in reality, resistance to harm reduction is typically a cloak for moral judgments about what constitutes responsible behavior. When people express worry that PrEP will promote condomless sex, it just reveals their preconceptions about what counts as responsible sex. This bias, in turn, perpetuates stigma, the low uptake of PrEP, and preventable HIV infections. Likewise, a moralistic approach to coronavirus prevention—including shaming anyone whose adherence to social-distancing measures is less than 100 percent—will ultimately fail. If public-health officials assume that guidance on strategies such as seksbuddies or double bubbles will promote risky behavior, they will miss a crucial opportunity to reduce the potential harms of actions that some Americans are already taking.
Instead of moralizing, harm reduction comes from a place of pragmatism and compassion. It accepts that compromises will happen—usually for perfectly understandable reasons—and aims to reduce any associated harms as much as possible. When issuing guidance on double bubbles in Canada, the chief medical officer of health for Newfoundland, Janice Fitzgerald, said kindly, “I hope that this will help reduce some of the social isolation we all feel, especially those living alone.” The Dutch guidance on seksbuddies acknowledged the struggles of isolation: “It makes sense that as a single [person], you also want to have physical contact.” Harm reduction is public health with a dose of empathy.
Americans have been told to wear masks, stay at least six feet apart, and wash their hands. But that’s not enough. People need to hear that, if they are desperate to see friends, they should do so outdoors as much as possible; that adding one other household to their quarantine group is much safer than adding five; that if a single person needs physical intimacy, having one partner—even if neither considers it a romantic relationship—is safer than a series of hookups; that they can stop disinfecting all their groceries while still avoiding higher-risk situations, such as spending time inside with large groups of people. The CDC is not providing enough pragmatic advice. There’s hope yet for state and local health departments, especially in places such as California and New York, where elected representatives have begun to publicly support a harm-reduction approach. But harm reduction is most needed in states that are opening prematurely—the same states that have historically rejected an empathetic approach to health in favor of a moralistic one.
In the meantime, the general public is developing its own guidance on how to cope with a pandemic, just as the gay community did in the early days of AIDS. Americans are making decisions every day about how to reopen their lives. They’re not going to wait for public-health officials to give them the okay—but they could still use advice on the safest way to go about it.