At the beginning of the outbreak, the United States had a chance to contain the novel virus by identifying each person bringing the infection into the country and stopping it before it spread in the community. We failed, with a lack of testing largely to blame. Instead of individual-level containment, which would have had minimal effect on the economy, we had to employ societal-level lockdowns to slow the explosive spread of the virus and buy us time until we developed the capacity to rein it in. The idea was that restrictions would be lifted once we reduced the number of infections far enough and built up the public health infrastructure needed to find new positive cases, trace contacts and quarantine those exposed.
Unfortunately, due to a late start, inconsistent state actions and a lack of federal direction, most states have yet to see a consistent decline in cases, much less reduced them to low enough levels for this to work. No state has achieved sufficient testing and contact tracing. Reopening under these circumstances means we are giving up on containing covid-19.
What’s next, then? The administration has yet to use these words, but it appears that we’re adopting a strategy that I recognize from other aspects of public health: harm reduction.
Harm reduction was initially developed as a public health approach to reduce the negative consequences of drug use. It recognizes that while stopping drug use is the desired outcome, many people won’t be able to do that. For those individuals, needle-exchange programs can reduce their risk of acquiring HIV and hepatitis and transmitting these infections to others. Such programs do not promote or condone drug use, as some critics contend. Rather, they face the reality that if a behavior with harmful consequences is going to happen regardless, steps should be taken to reduce the risk for both individuals and others around them. Think, too, of safe-sex campaigns, or motorcycle helmet laws.
And this seems to me where we are with covid-19: We’re no longer trying to eliminate the virus. Instead, we are accepting that Americans will have to live with it.
If that’s the case, then our efforts should pivot from justifying why reopening is a good idea to figuring out how best to reduce the harm it is certain to cause. If employees have to go to work, let’s at least come up with evidence-based practices that help them do so more safely. Should workplaces all get regular deep cleaning, close off any communal areas and meet new standards for ventilation? Can employees be mandated to wear masks, work six feet apart and keep a contact diary?
We know that covid-19 is most likely to be transmitted when a lot of people are in an enclosed area for a prolonged period. I would not have advised that hair salons and gyms open for business, but since they have in some states, we should aim to stop the highest-risk practices — prolonged treatments and crowded indoor fitness classes, for example. If people are going to get together in large groups despite the danger, we should at least advise that they do so outdoors, for shorter periods of time, and avoid practices with a higher likelihood of disease transmission, like sharing utensils and group contact sports.
A switch to harm reduction doesn’t mean the Trump administration is off the hook on testing and tracing. Regular, rapid testing will make it much safer for employees and students to return to work and school. Of course, there is also a fundamental difference between this new iteration of societal harm reduction and what I know as the standard public health practice of individual harm reduction — this disease risk is being forced upon the many Americans who would not have chosen it for themselves and their loved ones. That’s a real tragedy.
I wish the United States had taken a different path. We could have contained the virus earlier, and we still had a chance to do it until we reopened against the guidance of public health experts — including the Trump administration’s own top doctors. But now that we are where we are, we should at least be honest and call our new strategy what it is. It’s our best hope left for saving lives.
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