In the earliest years of the HIV epidemic, confusion and fear reigned. AIDS was still known as the “gay plague.” To the extent that gay men received any health advice at all, it was to avoid sex. In 1983, the activists Richard Berkowitz and Michael Callen, with guidance from the virologist Joseph Sonnabend, published a foundational document for their community, called “How to Have Sex in an Epidemic.” Recognizing the need for pleasure in people’s lives, the pamphlet rejected abstinence as the sole approach and provided some of the earliest guidance on safer sex for gay men, including recommendations about condoms and which sex acts had a lower or higher risk for disease transmission.
Public-health experts have known for decades that an abstinence-only message doesn’t work for sex. It doesn’t work for substance use, either. Likewise, asking Americans to abstain from nearly all in-person social contact will not hold the coronavirus at bay—at least not forever.
#StayHome had its moment. The United States urgently needed to flatten the curve and buy time to scale up health-care capacity, testing, and contact tracing. But quarantine fatigue is real. I’m not talking about the people who are staging militaristic protests against the supposed coronavirus hoax. I’m talking about those who are experiencing the profound burden of extreme physical and social distancing. In addition to the economic hardship it causes, isolation can severely damage psychological well-being, especially for people who were already depressed or anxious before the crisis started. In a recent poll by the Kaiser Family Foundation, nearly half of Americans said that the coronavirus pandemic has harmed their mental health.
Meanwhile, most public-health experts agree that a premature return to the old version of normalcy would be disastrous. States continue to lack the capacity for widespread coronavirus testing or contact tracing. Serologic testing to date suggests that the majority of the population is still susceptible to infection. A vaccine is months or even years away. New cases continue to rise, with thousands of people dying each day, and those numbers will inevitably increase if communities go back to business as usual.
But the choice between staying home indefinitely and returning to business as usual now is a false one. Risk is not binary. And an all-or-nothing approach to disease prevention can have unintended consequences. Individuals may fixate on unlikely sources of contagion—the package in the mail, the runner or cyclist on the street—while undervaluing precautions, such as cloth masks, that are imperfect but helpful.
Public-health campaigns that promote the total elimination of risk, such as abstinence-only sex education, are a missed opportunity to support lower-risk behaviors that are more sustainable in the long term. Abstinence-only education is not just ineffective, but it’s been associated with worse health outcomes, in part because it deprives people of an understanding of how to reduce their risk if they do choose to have sex. And without a nuanced approach to risk, abstinence-only messaging can inadvertently stigmatize anything less than 100 percent risk reduction. Americans have seen this unfold in real time over the past two months as pandemic shaming—the invective, online and in person, directed at those perceived as violating social-distancing rules—has become a national pastime.
The anger behind shaming is understandable. Photos of crowded beaches or videos of people at a large indoor party may make viewers feel as if they’re watching coronavirus transmission in action. Calling out seemingly dangerous behavior can also provide an illusion of control at a time when it’s particularly hard to come by. But, as years of research on HIV prevention have shown, shaming doesn’t eliminate risky behavior—it just drives it underground. Even today, many gay men hesitate to disclose their sexual history to health-care providers because of the stigma that they anticipate. Shaming people for their behavior can backfire.
Berkowitz and Callen knew that indefinite abstinence wasn’t realistic for everyone, and instead of shaming, tried to give gay men the tools they needed to be able to have sex with a low but non-zero risk of HIV transmission. In essence, this is the harm-reduction model, which recognizes that some people are going to take risks, whether public-health experts want them to or not—and instead of condemnation, offers them strategies to reduce any potential harms. This approach meets people where they are and acknowledges that individual-level decisions happen in a broader context, which may include factors that are out of people’s control.
What does harm reduction look like for the coronavirus? First, policy makers and health experts can help the public differentiate between lower-risk and higher-risk activities; these authorities can also offer support for the lower-risk ones when sustained abstinence isn’t an option. Scientists still have a lot to learn about this new virus, but early epidemiological studies suggest that not all activities or settings confer an equal risk for coronavirus transmission. Enclosed and crowded settings, especially with prolonged and close contact, have the highest risk of transmission, while casual interaction in outdoor settings seems to be much lower risk. A sustainable anti-coronavirus strategy would still advise against house parties. But it could also involve redesigning outdoor and indoor spaces to reduce crowding, increase ventilation, and promote physical distancing, thereby allowing people to live their lives while mitigating—but not eliminating—risk.
Second, health experts can also acknowledge the contextual factors that affect both a person’s decisions and their risk of coronavirus transmission. Some people are seeking human contact outside of their households because of intense loneliness, anxiety, or a desire for pleasure. The decision to go for a run with a friend or gather in a park with extended family may be in conflict with current public-health guidance in some communities, but for some people, the low risk of coronavirus transmission in these settings may be outweighed by the health benefits of human connection, exercise, and being outdoors. We can also acknowledge that some people can’t comply with public-health guidance because of structural factors, including systemic racism, that render physical distancing a privilege. If we ignore this broader context, people of color will continue to bear the brunt of not only the pandemic itself, but also American society’s response to it.
Third, Americans can accept that, despite our best efforts, some people will choose to engage in higher-risk activities—and instead of shaming them, we can provide them with tools to reduce any potential harms. Want to see your grandkids? Still planning to have that party? Meet up outside. Don’t share food or drinks. Wear masks. Keep your hands clean. And stay home if you’re sick.
As long as the Centers for Disease Control and Prevention is silenced, local and state health departments, epidemiologists, and clinicians may need to lead the way. The New York City Department of Health and Mental Hygiene and physicians at Harvard Medical School each created guidance on sexual health during the coronavirus pandemic that could provide a road map for a harm-reduction approach to socializing, work environments, schools, and other settings. They communicated the urgent need for physical distancing and the idea that, as the New York document puts it, “you are your safest sex partner.” At the same time, the New York and Harvard guidelines implicitly acknowledge that some people may choose to have sex within or outside of their households and offer tips to reduce harm in different potential scenarios, making the risk continuum clear.
The U.S. is in the midst of an infectious-disease crisis that has wrought global devastation and taken the lives of more than 75,000 Americans to date, with no end in sight. But, as other epidemics have shown, trying to shame people into 100 percent risk reduction will be counterproductive. What Americans need now is a manual on how to have a life in a pandemic. If no one else provides the guidance that the CDC won’t, each of us will need to figure out our own.
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