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Coronavirus Disease 2019
The Path Out of COVID-19 Means Letting Go of Certainty
How harm reduction can guide us through the pandemic.
Posted May 17, 2020
Today marks two months since California’s governor, Gavin Newsom, ordered the state to shelter in place to slow the spread of COVID-19 and to prevent hospital resources from being overwhelmed with SARS-CoV2 patients.
Even with Zoom meetings, socially distant trips outside to exercise, and grocery delivery, I think we can all agree on one thing—this is getting a little old. We’re all itching for a change. In some states, this itching has taken the form of reopening without restrictions, sometimes in response to pressure from armed protestors. Other states, such as New York, that have been badly walloped, have pushed the shelter-in-place orders out another month at least.
Advocates for reopening frequently invoke a theme of personal freedom and the need to maintain the economy, sometimes minimizing the risk posed by the SARS-CoV2 disease as similar to that of the flu. The advocates for remaining shut emphasize that without a vaccine (that may not be ready for one or two years, and assumes that the majority of the population would adhere to a recommendation to get vaccinated), we can never open safely.
Both are right and both are wrong. The longer this goes on, the more extreme voices seem to rise above the fray, making it seem like this is an argument between two polarized sides. That is a distortion.
I posit that the vast majority of people are reasonable, want to be safe, and they also want some semblance of their lives back. This is understandable, and yet, I have bad news for both of them. We’re never going to be completely safe, and we’re not going back to how it was before.
The path forward is going to be uncomfortable, protean, and uncertain. There is no perfect route, only varying degrees of “less bad.” Regardless of where you fall on the “reopen/keep it shut” continuum, you are likely to be uncomfortable in the weeks and months ahead.
For a guide through this conundrum, we can look to harm reduction. Harm reduction is a public health philosophy that acknowledges that some actions (like driving) are necessary, but they are also quite dangerous (39,000 people die in car accidents each year in the USA). We attempt to reduce the harm with technology (seatbelts and airbags), but also through agreed-upon rules (your right to remain safe on the road trumps my right to run a red light because I feel my freedom impinged upon by its ruby gaze) that govern our behavior.
Because we prefer order over chaos, we have made a tacit agreement to follow certain rules when we drive, and we have empowered an arm of the government (the police) to enforce them. While there are many valid arguments to be made about the arbitrary nature of some traffic laws, and the sometimes capricious way that they are enforced, you’d be hard-pressed to find an advocate for a total free-for-all on the roads.
In the early 1980s, the AIDS pandemic ravaged the community of gay men. When it was identified as sexually transmitted, the initial puritanical advice given was “don’t have sex.” While sex may seem optional to some (I would argue it is as natural as breathing), this public health strategy was not only unviable, it was also counterproductive, as it gave no guidance as to how to have sex more safely.
Harm reduction evolved out of the AIDS crisis by acknowledging that people were still going to engage in higher-risk behaviors, but that the risk of those harms could be reduced with technologies (condoms) and mitigated by behavior (discussing sexual histories with potential partners, being thoughtful about your number of sexual partners, engaging in less risky sexual activities).
These measures made the proponents of abstinence at best, uneasy, and at worst livid at what appeared to be a condoning of sexual activity that risked HIV transmission. To those who were being asked to limit their sexual activity or to use condoms, such requests were seen as impositions on the hard-fought freedoms brought about by gay liberation.
But despite the uneasiness of the abstinence advocates and those who wanted unrestricted sexual expression, harm reduction worked, and it is now a standard, essential practice for HIV prevention. Julia Marcus, a professor of Population Medicine at Harvard, made an argument for a harm reduction approach to COVID-19 in a recent article in The Atlantic.
In some ways, the perfect solution will leave no one perfectly comfortable. We are going to be asked to endure a certain degree of unease in the weeks and months ahead. Part of that discomfort will come from the inconsistency of these official guidelines. The cynic will make a case that authorities changing the guidelines is a sign of incompetence. On the contrary.
Inconsistency of the official warnings is inevitable when scientists are still learning about the behavior of a novel disease. The guidelines that were relevant last month may be changed in the future as we learn more and revise our knowledge.
These changes should not be a reason for not believing the guidelines. On the contrary, the willingness of public health authorities to iterate their guidelines as new information becomes available should increase the trust that such information is current and accurate.
But we humans do not like inconsistency. It raises our suspicions of incompetence, or worse, nefarious intent. But this inconsistency is one of the discomforts we will have to endure to find our way out of this pandemic.
Another counterproductive approach is shaming those who do not follow social distancing guidelines. Those doing the shaming often come from a fear of the disease and a feeling of powerlessness to do anything to stop the virus from spreading.
Shaming others who appear to be flaunting their freedoms on social media when we are held up in our houses might be smugly satisfying, but ultimately when we feel shame, we tend to do one of two things: galvanize ourselves into the certainty of our position, or hide our behavior once it is called out. Neither response is helpful in a time when we need to remain nimble and malleable in our responses and also transparent in our behavior in order to protect one another.
Engagement and gentle education are a better approach, especially if the fears are grounded in our own experience (it has more weight for me to tell a friend that I am worried about my grandmother’s health than it does to speak about the abstractions of epidemiology).
Until there is a prophylactic medication that prevents transmission or infection, or better yet, a vaccine, we are all going to have to learn to tolerate a measure of risk, perhaps more than we are already doing. A mask is like a condom for your face—it is uncomfortable, we’d rather not use one, and it doesn’t remove all risk, but by wearing it we protect ourselves, but more importantly, we protect others, so we’ll probably need to get used to wearing them for a time to come.
The physician William Ostler was quoted as saying that medicine is, “A science of uncertainty and an art of probability.” That is to say that we are always weighing changing probabilities against each other in order to make reasonable decisions. If we reopen too soon, we run the risk of new outbreaks. If we wait too long, we could be facing increasing deaths of despair from the fallout of a ruined economy.
As we sway back and forth, trying to find our balance, we’re likely to veer too far to one side and then react by overcorrecting. This is to be expected. As we make mistakes, it is important that we approach those mistakes with humility. While we may feel our view is validated when a restriction is lifted without incident, or worse, feel an uncomfortable sense of vindication when seeing numbers rise following the premature lifting of restrictions, we need to view these errors as dispassionate data, not as an exculpation, and act accordingly to make reasonable, logical adjustments to mitigate risk.
This process of finding our way back to a new normal will call on all of us to surrender at times—to surrender our fears (be those fears of infection or of loss of freedom); to surrender our certainty (we are still in the process of understanding this virus, and while facts are rapidly accruing, there is still much to learn. It is important, though, not to mistake the absence of evidence as evidence of absence—just because we don’t yet know something about this virus, doesn’t mean it’s not possible); we will also have to surrender our belief in absolute certainty. This is going to be a deeply uneasy time.
It takes an act of great humility to say, “we don’t yet know.” It’s tempting to allow our current beliefs to crystalize in a polarized and immutable position. But the path forward will likely be somewhere in the messy, uncomfortable middle where we slowly move forward, not allowing the perfect to be the enemy of the good.
