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Not Letting the Perfect Be the Enemy of the Good

Lessons from HIV/AIDS about harm reduction in a time of COVID-19.

In my previous blog post, I wrote about the lessons that can be learned from the HIV/AIDS pandemic that we can utilize as we address COVID-19. One of the most important lessons we can take away is harm reduction—not letting the perfect be the enemy of the good.

In the absence of adequate treatment, prevention is best, followed by prophylaxis.

Once HIV was identified in certain bodily fluids and as largely sexually transmitted, targeted prevention could begin. Barring abstinence, condoms were advised as the best method for preventing HIV transmission. Similarly, the widespread use of masks has been advised as a means of limiting the spread of COVID-19.

In 2012, the FDA approved the use of pre-exposure prophylaxis (PREP), a daily medication meant to reduce the likelihood of contracting HIV if exposed to the virus. In addition to encouraging those who are HIV positive to take antiretroviral medication to reduce their viral load to an undetectable level to prevent transmission, these two measures have driven down infection rates, particularly in countries that can offer citizens access to these technologies.

While several drugs, including the much-touted hydroxychloroquine, have been explored as prophylaxis against COVID-19, an effective one has yet to be discovered. As such, until an effective prophylaxis is found, prevention of transmission continues to be our best bet for containing the spread.

It may be a long time before a vaccine is available. Until then, harm reduction is a viable approach.

In 1984, it was speculated that a vaccine for HIV was two years away. Thirty-six years later, research continues towards this critical goal. A COVID-19 vaccine may be, at best, a year away. However, until a vaccine is available, harm reduction can reduce the risk of infection. Harm reduction is a public health philosophy that acknowledges that certain behaviors (in the case of HIV, it was sex. For COVID-19, it is socializing and working with others) are normal and human.

Harm reduction attempts to reduce the potential harm associated with these behaviors. It is a philosophy that acknowledges that risk is not binary and that most human behavior has an inherent degree of risk that can be reduced through our choices and behaviors and through the use of technology. In the case of AIDS, condoms were a technology that reduced the risk of HIV transmission and considered selection of sexual partners was a behavior that reduced risk. Neither was 100% perfect, but the benefit was significant enough to significantly reduce transmission rates.

How do we practice harm reduction with COVID-19?

It’s becoming clearer that the duration of time that we spend around others, the degree of proximity, the use of masks, and if we encounter others outside or inside greatly influences transmission.

While it may be possible and ideal to separate ourselves from others for a short period of time, it’s increasingly clear that this is not a viable long term plan. But the perfect needn’t be the enemy of the good.

Let’s start with masks. Yes, they are uncomfortable. Yes, they make it difficult to understand other people’s speech and facial expressions. Yes, they give public spaces an apocalyptic vibe. Like condoms, most people would rather do without them, but they serve a similar role—to protect one another. (This grandson in the UK came up with a creative way to hug his grandmother.) The data is increasingly clear—widespread use of masks reduces transmission. The challenge is that the protection is primarily for the person around the mask-wearer, and less for the person wearing the mask. Therefore, when we wear a mask, we protect each other.

There are still many ways we can enjoy our activities. We can see each other; we just can’t do it in large groups, and we should probably meet up outside. Recently, my family had a picnic with another family. We met in a large park, didn’t share food, and sat six feet apart from each other. While I missed the hugs that usually come with meeting them, it was lovely to enjoy company, sunshine, and conversation together. Distance doesn’t need to mean divided or isolated. While the term “social distancing” has become the new phrase of 2020, it’s really physical distancing that reduces the risk of spread. And while a little picnic may not be as fun as a big potluck gathering, it certainly was better than nothing at all.

Clearly, some places where we gather may be easier to adapt to open spaces and fresh air. I suspect restaurants may start turning parking lots and sidewalks into outdoor dining rooms. That will be easier in the suburbs than in dense urban areas. Movie theatres, concerts, festivals, and sports arenas are probably going to be out for a while, large, indoor religious services will need to wait, weddings will need to be postponed, and conferences will probably stay online until this is better contained. Bicycling may enjoy a surge of popularity by combining exercise, transportation, and the ability to avoid crowded public transportation. Camping may be a safer way to go on a summer vacation this year.

Coming to peace with imperfect measures is a critical component of harm reduction. This approach requires us to make our best efforts to contain the spread of the virus, knowing that even they will fail sometimes, but at the same time, not succumbing to the nihilistic temptation of refusing to change and saying, “why bother, it doesn’t matter anyway.” It’s helpful to avoid shaming those who, possibly out of ignorance or wishful thinking, are exercising less caution than we are, as shame tends to lead people to double down on their position or to hide their behavior, neither of which will be helpful in containing this virus. When the behavior is hidden, it cannot be engaged or changed. We can learn from the lessons of HIV that gentle but persistent health messaging and flexible approaches rooted in harm reduction are a better strategy for reducing the risk of COVID-19 transmission.