Thursday, March 25, 2021

32. We Are All Harm-Reductionists Now

I learned on January 7, 2021, that I received two full doses of the AstraZeneca COVID19 vaccine in November and December of 2020.  I was officially unblinded in the clinical trial after essential workers in New York State had become eligible to receive the shots and I did not want to get two.  During this discussion I was basically told, “With two full doses you are about 74% less likely to get COVID19.  But if you do get COVID19 it is extremely unlikely that you would get sick from it, and the antibodies would make the viral load so low that it is nearly 100% untransmittable to others.  However, there are still a lot of strains mutating out there and we don’t know how much protection you will have from the newer versions.  It is likely you will have protection from most, but maybe not as much protection from others.  It is important to still wear masks because they further reduce the potential for spread.”  In other words, “Live your life but take reasonable precautions not to harm yourself or others.”  

Suddenly, this conversation felt very familiar.

When I started having sex with men in 1989, AIDS was still rampant throughout the gay male community.  Efficacy of the medical tests was poor given they only gave you an estimate of whether you had AIDS six months prior to when the test was given.  It was estimated a very high percentage of the community had AIDS and didn’t know it [note I’m using the terminology “AIDS” instead of “HIV” because that was the commonly used term at the time].  

I knew having sex with other men could lead to death.  But I was also told that condoms offered about 90% protection, give or take.  In my horny teenage mind, I remember negotiating, “Okay, 90% is not 100% but it certainly makes it less likely I can have sex without traumatic outcomes so I’m willing to go with that.”  I used the calculations to decide for myself what level of risk was acceptable, and set out to enjoy myself while actively reducing potential harm.     

When I started volunteering at Larkin Street Youth Center in 1994, part of my training was to learn about needle exchange and street outreach.  The message was, “We’re here to save lives not to judge” and how needle exchange was one of the most effective and essential forms of preventing AIDS in San Francisco.  They shared with us a framework called “Harm Reduction” that asserted people had the right to clean needles so when they used IV drugs they would be less likely to pay for it with their lives.  It seemed to me that needle exchange and condoms had a lot in common -- they both respected the right to enjoy pleasure, and/or to do sex work for survival, without having to die for it.   Over the years as I worked in outpatient substance abuse agencies and methadone, this compassionate tenant would inform interventions again and again.  

When I first learned in detail about the science that supported PrEP use in 2011, the estimate was that daily use of PrEP would reduce risk of acquiring HIV by about 92%.  In my horny 40s mind I remember negotiating, “Okay, 92% is not 100% but it certainly makes it less likely than I can get HIV by having sex without condoms so I’m willing to go with that”  Once again, I used the calculation to decide for myself what level of risk was acceptable, and set out to enjoy myself while actively reducing potential harm.  [Later it was determined that daily use of PrEP actually reduced risk of HIV by nearly 100%.]  

Harm reduction means getting as many facts as you can, gathering the available data, and then making a calculated risk accordingly.   It means asserting that the quality of your life is meaningful, that fun is valuable, and if given enough knowledge and tools you can take relevant steps to mitigate and reduce negative consequences from your choices.  It is rarely a sum-zero game, it is usually an active weighing of options that help to ultimately arrive at the point,  “This decision will allow me to have the maximal experience with the minimal consequences.”  

Other common everyday examples of practicing harm-reduction include using seat belts in cars, helmets while playing football, statins to lower cholesterol, wearing sunscreen on the beach, harnesses while bungee jumping, taking self-defense courses, and so on.  None of these protections are 100%, but they can give the individual an opportunity to participate in life and enjoy fun and necessary activities while actively anticipating and preventing harm.  

As much as I respect Dr. Anthony Fauci, I will say that he gave some pretty confusing and contradictory advice about mask wearing early on (and he has acknowledged this as well).   At first we were told consumer masks weren’t effective for COVID19 protection because the small droplets could still seep through.  Then we were told masks were recommended (and in some areas required).  These conflicting and unclear messages lent themselves to push back, debates, and eventually political polarization.

In my opinion, a lot of that confusion and anger could have been avoided if medical authorities had just called masks what they are:  Harm-Reduction.  They are not 100% effective, but they are quite good at protecting from receiving and transmitting COVID19 . Exactly how well they work is uncertain, but we know more and more from data (areas where mask wearing is mandatory) that it has a significant impact.  People were able to wear masks last summer and still attend large outdoor gatherings, Black Lives Matter protests, social events, outdoor dining, all with very little known or documented COVID19 transmissions.   If masks had simply been rolled out early as a harm-reduction strategy, as a way to do the things you want to do while mitigating the risks, (like condoms, needle exchange, seat belts), then I I would have gotten on board with the practice much earlier, and I believe there would have been a lot less public resistance. 

Today when I see people debating using masks, or taking vaccines, they inevitably are coming from an all-or-nothing position.  They are arguing that these mitigations are not efficacious because they are not 100% protective.  Harm-Reduction allows us decades of empirically driven data to show that reducing risk, while not 100%, can greatly benefit communal health outcomes.  Yet for some reason, medical authorities and policy leaders still seem reluctant to help people understand masks and vaccines this way.   

One's individual risk tolerance varies from person to person.   Some folks like myself seem to have a higher tolerance for risk, and some people have a lower tolerance for risk.  Some people are using facts to calculate that it’s okay to hug parents and grandparents when everyone is vaccinated, and others seem to feel that it’s too soon to do that.  Harm-reduction teaches us to respect and appreciate different people's comfort levels and help them make decisions that feel the most proactive, responsible, and empowered, about their pleasure and protection. 

In this respect it is misguided to ask the question, "Can I visit my parents now?" The accurate question would be, "What level of risk am I willing to accept?" If everyone has been vaccinated then the risk of getting or transmitting COVID19 is pretty darn low.  But we are no longer operating a world where that risk is zero. 

One thing that is for certain - COVID19 isn't disappearing anytime soon.  New strains are mutating as we speak.  Going to restaurants, bars, theaters, concerts, shopping malls, weddings, funerals, churches or spiritual gatherings, may never be completely COVID-risk-free again.   For the foreseeable future everyone is going to have to mitigate social risks and make their decisions accordingly.  I think this would go a lot smoother if public officials communicated what we learned about about preventing AIDS in the 1980s:  Learn the facts, evaluate your risk, take reasonable protections, and then have some fun!  

 To learn more please visit Harm-Reduction International

Damon L. Jacobs is a Licensed Marriage and Family Therapist helping individuals and couples enjoy life with peace, purpose, and pleasure. His books "Absolutely Should-less" and "Rational Relating" help people experience connection with joy, serenity, and meaning. His work has been featured on CNN Health, The New York Times, MSNBC, USA Today and more. He can be reached at or 347-227-7707

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