Yet one can hardly imagine the Centers for Disease Control and Prevention making such a recommendation—and not just because American health agencies are less relaxed about sexual matters than their Dutch counterparts are. It’s also because, even as states begin to ease social-distancing rules, Americans are receiving very little help in resolving any of the countless practical dilemmas they are encountering every day.
This month, the CDC finally released guidance for businesses, schools, child-care facilities, and other entities on when and how to safely reopen. But if you’re one of the many Americans who’s trying to figure out how to reopen your life, you’re not likely to find answers in those 60 pages. What’s the safest way for your family to start socializing with other households? How can you begin seeing friends or dating again while still minimizing your risk of contracting or transmitting the coronavirus?
Creating nuanced public-health guidance that can help answer these questions is no easy task, but it can be done. In fact, it is being done—just not in the United States.
The seksbuddy suggestion tells Dutch citizens that, even if they do not abstain indefinitely, they can still seek out lower-risk ways of having sex. Likewise, individuals and families can modestly expand the number of friends whom they see in person without abandoning caution altogether. Several provinces in Canada have issued guidance on “double bubbles ,” a similar approach for social, rather than sexual, contact. In this model, two households can agree to have an exclusive relationship with each other without the need for physical distancing. Every additional social interaction increases risk. But with clear communication and continued social distancing from other households, the double-bubble model could give people enough social contact that they’d be more inclined to forgo the crowded parties now popping up around the country—events that have the potential to spread the virus far beyond those who choose to attend.
That’s what harm reduction for the coronavirus pandemic can look like. Unlike abstinence-only messaging, which simply instructs people to stay home, a harm-reduction approach acknowledges that people will take risks for a variety of reasons, including a basic need for pleasure. If coronavirus risk behavior follows the pattern of other health conditions, people who attempt to deny themselves any human contact outside of their household for months on end may be more likely to abandon risk-reduction strategies entirely. Such a scenario could have dire consequences. The abstinence-only and harm-reduction approaches share the same goal of reducing the cumulative burden of severe illness and death. But harm reduction is more likely to achieve that goal by supporting lower-risk—but not zero-risk—activities that can be sustained over time.
What’s holding the U.S. back from providing guidance on seksbuddies and double bubbles? Unlike the Netherlands and provinces in Canada, many parts of this country continue to have enough community spread of the coronavirus—and too little testing and contact tracing—that actively recommending such strategies would be premature. But here’s the thing: Whether public-health officials like it or not, some Americans are already expanding their social and sexual circles, and they desperately need guidance on the safest ways to go about it.
This country has always been slow to embrace harm reduction, a resistance that dates back to our Puritan roots. The oft-cited concern is that offering people strategies to reduce the harms of risky behavior will end up promoting that risky behavior. It’s no surprise that this concern comes up most frequently in the highly moralized contexts of sex and drug use. People have argued against providing the HPV vaccine to teens out of concern that it will lead them to have sex earlier or with more people, even though no evidence shows this to be the case. People have argued against providing sterile syringes to those who inject drugs out of concern that it will encourage more frequent drug use. It doesn’t.
In my own field of HIV research, concerns about increases in risky behavior have dogged pre-exposure prophylaxis—PrEP, a pill to prevent HIV—since it was introduced almost a decade ago. The concern is that giving people PrEP will lead to decreased condom use, which could expose them to other sexually transmitted infections and potentially increase the risk of contracting HIV. On these grounds, some clinicians hesitate to prescribe PrEP even though it provides nearly 100 percent protection against HIV—and even when patients are already using condoms inconsistently.
The concern about harm reduction causing riskier behavior has already arisen in the U.S. coronavirus response. It contributed to the dallying in regard to mask recommendations in March and April, with public-health officials worrying that masks would promote riskier social contact by giving people a false sense of security. “We don’t want people to get an artificial sense of protection because they’re behind a mask,” Deborah Birx , the White House’s coronavirus-response coordinator, said early last month. “This worries us.” (The next day, the CDC urged Americans to wear masks in public.)
In all of these examples, a concern about the promotion of risky behavior masquerades as a concern about health. But in reality, resistance to harm reduction is typically a cloak for moral judgments about what constitutes responsible behavior. When people express worry that PrEP will promote condomless sex, it just reveals their preconceptions about what counts as responsible sex. This bias, in turn, perpetuates stigma , the low uptake of PrEP, and preventable HIV infections. Likewise, a moralistic approach to coronavirus prevention—including shaming anyone whose adherence to social-distancing measures is less than 100 percent—will ultimately fail. If public-health officials assume that guidance on strategies such as seksbuddies or double bubbles will promote risky behavior, they will miss a crucial opportunity to reduce the potential harms of actions that some Americans are already taking.
Instead of moralizing, harm reduction comes from a place of pragmatism and compassion. It accepts that compromises will happen—usually for perfectly understandable reasons—and aims to reduce any associated harms as much as possible. When issuing guidance on double bubbles in Canada, the chief medical officer of health for Newfoundland, Janice Fitzgerald, said kindly , “I hope that this will help reduce some of the social isolation we all feel, especially those living alone.” The Dutch guidance on seksbuddies acknowledged the struggles of isolation: “It makes sense that as a single [person], you also want to have physical contact.” Harm reduction is public health with a dose of empathy.
Americans have been told to wear masks, stay at least six feet apart, and wash their hands. But that’s not enough. People need to hear that, if they are desperate to see friends, they should do so outdoors as much as possible; that adding one other household to their quarantine group is much safer than adding five; that if a single person needs physical intimacy, having one partner—even if neither considers it a romantic relationship—is safer than a series of hookups; that they can stop disinfecting all their groceries while still avoiding higher-risk situations, such as spending time inside with large groups of people. The CDC is not providing enough pragmatic advice. There’s hope yet for state and local health departments, especially in places such as California and New York, where elected representatives have begun to publicly support a harm-reduction approach. But harm reduction is most needed in states that are opening prematurely—the same states that have historically rejected an empathetic approach to health in favor of a moralistic one.
In the meantime, the general public is developing its own guidance on how to cope with a pandemic, just as the gay community did in the early days of AIDS. Americans are making decisions every day about how to reopen their lives. They’re not going to wait for public-health officials to give them the okay—but they could still use advice on the safest way to go about it.
