How harm reduction models can save US lives in the pandemic

·9-min read
<span>Photograph: Apu Gomes/AFP/Getty Images</span>
Photograph: Apu Gomes/AFP/Getty Images

Over the course of the pandemic, the stark political divide in the US around implementing public health measures has at times been as perplexing for public health officials as the virus itself.

On the one hand, the former Republican president Donald Trump avoided making any clear directives about Covid-19 while he was still in office last year, and the conservative talkshow host Tucker Carlson likened mask-wearing for children to “child abuse”. On the other, something as simple as easing restrictions on outdoor masking has revved up a new heated debate among cautious residents of Democratic cities.

Related: The US won’t reach herd immunity this year. So how will it live with Covid?

“In the United States, our federalist approach to government creates problems. And I’m not recommending we do away with it, but I do think we have to come up with creative solutions to responding to epidemics,” said Ricky Bluthenthal, an associate dean at the University of Southern California Keck School of Medicine. He pointed out that while scientific expertise and emergency response lies at the federal level, states and local governments are in charge of implementing them.

But though the specific circumstances of this moment and country seem unique, some experts say that another, time-tested approach could have helped cut through some of this polarization and the culture wars: harm reduction.

The principles of the harm reduction model can differ, but focus on some core concepts. It accepts that some people will continue harmful behaviors. It aims to build a healthy community without judgment or coercion, providing other health-focused services. It also tries to minimize risky behavior by carefully tailoring messages, and choosing trustworthy messengers to approach each community instead of relying on broad government guidance.

While harm reduction has largely been used to combat drug abuse and HIV/Aids, experts say it could inform the coming months, and how the US tackles other health crises in the future.

A shift from shaming to listening

Since the idea of a Covid-19 vaccine was introduced last year it has been met with skepticism in some quarters. Almost half of Republican men surveyed said they are not planning to take the Covid-19 vaccine. And many other Americans hesitant about the vaccines have been seen as anti-vaxxers – a term otherwise reserved for a very small population of people who believe inoculation is harmful.

To combat this, public health officials have largely pushed studies and fact-based arguments in their attempt to enforce mask mandates and vaccines. And Democrats have campaigned on the idea that they are the “party of science”.

But through the lens of harm reduction, that approach could backfire.

We think ‘people just need to hear the facts’. No, you need to acknowledge these feelings are real

Emily Bancroft

“Whether or not you believe the misinformation or belief someone holds, that belief is real to them,” said Emily Bancroft, a public health expert who consults with governments and local partners across Africa to deliver healthcare through the non-profit Village Reach. “We think ‘people just need to hear the facts’. No, you need to acknowledge these feelings are real.”

Bancroft gave the examples of a widespread belief in witchcraft in Malawi. When setting up a prenatal health hotline for expectant mothers, health workers would often encounter these local beliefs that contradicted evidenced-based health guidance. But rather than attempting to dispel these ideas, the workers were trained to acknowledge them, and then advocate for healthy practices throughout the prenatal and postpartum process.

Recently, the media outlet Vice talked to Americans who were scared about getting the Covid-19 vaccine for various reasons, including side-effects or how recently the trials happened. When asked why many of them eventually changed their minds, it wasn’t facts or science, it was knowing someone who was immunocompromised, or even watching devastating news from other countries on TV.

In other harm reduction models, combating risky behavior can mean trying to engage people in an intervention without judgment, whether or not they comply with the specific guidance.

In recent years, for example, public health workers have shifted from trying to get people who suffer from substance use disorders to cease all drug use and instead try to minimize risky behaviors such as sharing needles, which can spread infection and viruses. For example, a harm reduction group in Baltimore houses syringe service programs, but also ancillary services to build trust, said Susan Sherman, a Bloomberg professor of American health in the department of health, behavior and society at Johns Hopkins and co-director of the Baltimore HIV laboratory.

A woman is comforted by a health worker as she sits at the bedside of her husband at a Covid unit in Fullerton, California, on 31 July 2020.
A woman is comforted by a health worker as she sits at the bedside of her husband at a Covid unit in Fullerton, California, on 31 July 2020. Photograph: Jae C Hong/AP

In the case of Covid-19, the interventions would be different, but could focus on having people wear masks in the highest-risk situations, instead of most of the day, or focusing on vaccinations for only the most vulnerable groups.

“Setting up masks versus business is a false dichotomy, just like sterile syringes versus drug treatment, is false dichotomy,” Sherman said, pointing out that many people who were ardently opposed to wearing masks throughout the pandemic also felt that Covid restrictions were unnecessarily harming the economy and business owners.

Choosing the right messenger

Working with a population that is distrustful of the government, or authority, also requires taking culture and history into account when choosing which messenger and medium to inform the public.

In Israel, a significant population of ultra-Orthodox Jewish families did not want to get vaccinated, partly because of unfounded conspiracy theories, according to NPR. One ultra-Orthodox government consultant, Ari Blumenthal, found a tragic but effective window of opportunity. When a young, pregnant woman died after refusing a vaccine he asked the family for permission to share her story. The family, too, started to speak publicly about their loss. It humanized the risk, and the community started to get vaccinated at higher rates.

A similar strategy reached some of the last people in India who were refusing to get the polio vaccine. Some Muslim communities were fearful because of widespread distrust of the government and rumors about the vaccine containing pig products, which they do not consume. It was only when science-minded imams, or religious leaders, stepped in and publicly vaccinated their own children that things began to change.

Finding those messengers in the US can prove a challenge, said Sheila Davis, the CEO of Partners in Health who holds a doctorate in nursing. While many countries have built a system of community health workers over time, the US relies mainly on doctors offices or clinics, making it hard to disseminate more personalized information.

A woman passes out masks to people standing in line for Covid testing in Immokalee, Florida, on 7 June 2020.
A woman passes out masks to people standing in line for Covid testing in Immokalee, Florida, on 7 June 2020. Photograph: Lynne Sladky/AP

Davis’s organization has attempted to fill some of those gaps. In high-risk communities such as agricultural Immokalee, Florida, or neighborhoods of Chicago they set up community health teams to figure out the needs of the population. She also pointed out how quickly vaccination programs were carried out in Navajo communities because the tight-knit communities already had built-in communication systems and leaders who they relied on for information.

“They were very clear who was the most vulnerable in their communities, and who needed the most support,” she said.

Treating the whole community

While much of US Covid-19 interventions have been focused on masks, social distancing and vaccines, those working with high-risk communities say that the best public health models take into account the whole community and their needs beyond the specific virus.

Davis said getting people vaccinated against the virus is only one part of the picture in communities like Immokalee – Partners in Health also provided food assistance, mobile rapid testing, financial aid and other social services to 35,000 households.

It’s providing tangible, concrete things – making sure we’re addressing the whole person

Sheila Davis

“It’s providing tangible, concrete things – making sure we’re addressing the whole person,” she said. That includes making things like vaccines and masks as easy to obtain as possible.

Similarly, Sherman’s group in Baltimore offers showers, clothing, reproductive health consultations and other services to women suffering from drug abuse to keep them engaged in the system and get a sense of their needs. “Harm reduction organizations are nimble, they know how to ramp up their services and meet people where they are,” Sherman said.

This approach could also serve to address the economic concerns families faced during the pandemic, and the frustration with lockdowns and other safety protocols that were sometimes viewed as a threat to livelihoods, income and education. Closing schools, for example, might have been done more judiciously since children remain at low risk for contracting Covid-19.

“That has downward impacts – schools in other countries were not closed throughout the pandemic. Perhaps that would have gone a long way and would’ve been a neutralizer,” Sherman said.

Looking forward

The US is at a pivotal moment in the pandemic. About half of the adults in the country have received at least one dose of the Covid-19 vaccine, while the virus claims thousands of lives every day in countries like India and Brazil, threatening the progress made across the globe.

In some ways, it’s not the government, or the virus trends, but communities of people who will decide when the pandemic ends. For example, Joe Biden’s administration announced last week that vaccinated Americans don’t need to wear a mask when outside as long as they are not in densely populated settings. But even with a greenlight from the highest public office, many vaccinated people in cities like New York, Boston and Washington DC continue to wear their masks outside.

While the political system is not bound to change any time soon, public health experts said there are lessons to make it easier to keep people safe in the coming months.

“You have to segment your audience and tailor your message,” Sherman said. “If we set the foundation, and set the message about liberty centered around the person who could get the virus – that could make a difference.”

And if we’re vigilant, the US could even emerge from the pandemic with a stronger network of messengers than it began with, even if disagreement and discord remains.

“We can really use this opportunity to build a public health and community workforce that didn’t exist before,” Davis said. “And we may not be able to combat the final percentage [of people who don’t want vaccines] but I focus my energy and attention on people who are wanting to try and make a difference.”

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