Can sex ed and needle exchanges teach us how to live with a pandemic?

The philosophy of harm reduction could show Americans how to navigate the gray area between practicing total isolation and flouting social distancing and public health advice.
Patrons practice social distancing on the lawn at Tampa's Armature Works in May. Experts say harm reduction is a strategy that can help the public learn to take more precautions and reduce their risks while living through the pandemic.
Patrons practice social distancing on the lawn at Tampa's Armature Works in May. Experts say harm reduction is a strategy that can help the public learn to take more precautions and reduce their risks while living through the pandemic. [ LUIS SANTANA | Times ]
Published Jun. 8, 2020

Julia Negron sometimes refers to her work with the Suncoast Harm Reduction Project as “meeting people where they’re at,” a phrase that captures the organization’s philosophy, and its actions, like lobbying for needle exchange programs and distributing the overdose-reversing drug naloxone.

But like many, her job changed with the COVID-19 pandemic. She’s been staying home in Sarasota County, where she homeschools her grandson, organizes webinars and leaves naloxone in her mailbox so people can pick it up anonymously.

As Florida started to reopen this month, Negron said she’s been careful about staying in, because she has a chronic illness and doesn’t want to take risks. But for all the weirdness wrought by the coronavirus, one aspect of this moment doesn’t feel so alien to her: the realization that people can’t stay inside forever, and that the next few months will be more about mitigating the virus’s spread than trying to contain it.

Julia Negron, who founded the Suncoast Harm Reduction Project.
Julia Negron, who founded the Suncoast Harm Reduction Project. [ Courtesy of Julia Negron ]

“I always think in those terms,” she said.

It’s called “harm reduction” and it aims to help the public take more precautions rather than avoid risk entirely. It might mark a path forward at a crucial moment in this pandemic.

The question is whether a polarized America is even willing to take that path.

Related: After reopening, Florida hasn’t seen a spike in coronavirus cases. Are we in the clear?

• • •

Harm reduction favors accepting that people will do risky things and deciding it’s better to try to make those things less risky.

The term most often refers to tactics like Negron’s, which are aimed at reducing overdoses and blood-borne disease spread among those who use drugs. It also can be used when talking about comprehensive sex education.

In recent weeks, as people have flocked to reopened restaurants and beaches, doctors with national platforms have pointed to harm reduction. They suggest that the road to the future isn’t painted black and white — in commands to stay inside or assurances that everything is back to normal. Instead, it’s shades of gray.

Dr. Julia Marcus, an epidemiologist and assistant professor at Harvard Medical School.
Dr. Julia Marcus, an epidemiologist and assistant professor at Harvard Medical School. [ Courtesy of Julia Marcus ]

Dr. Julia Marcus, an epidemiologist and Harvard Medical School assistant professor whose research focuses on HIV prevention, says photos of those gathering in newly reopened beaches and parks have spread online recently — and the resulting vitriol reminded her that public shaming didn’t stop HIV from spreading.

It only made people reluctant to ask for help.

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“When we think about abstinence-only messaging, that’s an approach that tells people what the safest option is but doesn’t tell people about other possibilities,” she told the Tampa Bay Times. “It tends to not work.”

Marcus has become perhaps the most prominent advocate for a harm reduction approach to the coronavirus, after she wrote an article for The Atlantic magazine arguing that “pandemic shaming” won’t keep people from going outside, and that Americans need a realistic guidebook for how to live in the space between total isolation and acting like nothing’s wrong.

Dr. Linsey Grove, a sex educator in Pinellas County.
Dr. Linsey Grove, a sex educator in Pinellas County. [ Courtesy of Linsey Grove ]

Dr. Linsey Grove, a Pinellas County sex educator who teaches at the University of South Florida St. Petersburg, said that after a spring spent in quarantine, people will inevitably give into their urges to see friends and loved ones.

“It’s the same thing as expecting people to just not have sex — it’s just not biologically how we’re built,” she said. “In the same vein, we’re a social species.”

• • •

Experts say clear public health messaging is necessary. It could help convince people to do what doctors have pleaded for all along: wear a mask when they go out, to sit outside rather than inside for drinks, and to stay 6 feet apart the whole time.

Related: As Florida relaxes COVID restrictions, many still choose to stay at home

Sara Isaac, the director of strategy and planning for Orlando-based Marketing For Change, which uses marketing campaigns to alter social behavior, said the public needs unified directives. But instead of a unified national response, state and local health departments have been left to create a disjointed patchwork of responses.

The Trump administration initially buried what could’ve been a consistent reopening framework from the Centers for Disease Control and Prevention, the Associated Press reported in May. An edited version of the guidelines was released a week later, after the shelving was reported, and more guidance about houses of worship followed, though the administration later quietly removed some of those warnings. Polls show most adults trust public health officials — 79 percent, according to an April poll by the Pew Research Center — but theirs aren’t the only voices being amplified.

As people emerged from lockdown, it was hard to tell what constitutes model behavior: Do you emulate the neighbor who wears a mask to open the door for the plumber? Do you follow the lead of the friend posting selfies from a crowded bar? Do you cobble together an in-between personal policy?

Tampa Bay has had a front-row seat to that confusion. While Gov. Ron DeSantis resisted shutting down the state in March, leaders in Hillsborough and Pinellas counties passed their own “safer-at-home” orders.

Then on April 1, the governor issued his own statewide shutdown order — but some of his directives superseded local orders, causing more confusion.

There is still wide support for such measures, despite high-profile protests against shutdown orders in states like Kentucky, Michigan and Texas. A Washington Post-ABC News poll released June 1 found that 57 percent of Americans thought controlling the virus’s spread was still more important than restarting the economy

Sara Isaac, a principal at the Orlando-based firm Marketing for Change, said America's scattered public health messaging makes it harder for people to understand how to live during the pandemic: "We're all over the map."
Sara Isaac, a principal at the Orlando-based firm Marketing for Change, said America's scattered public health messaging makes it harder for people to understand how to live during the pandemic: "We're all over the map." [ Courtesy of Sara Isaac ]

“We’re all over the map with the messaging, which leaves room for a lot of confusion, and there are no clear social norms,” Isaac said. “Social norms drive a lot of what we do — we think we react because of logic, but often we take our cues by looking around and seeing what’s acceptable.”

On Memorial Day, for instance, President Donald Trump visited Arlington National Cemetery and did not wear a mask, which his staff is required to do inside the White House. His likely opponent in the fall, former vice president Joe Biden, wore a mask when he visited Delaware Memorial Bridge Veteran’s Memorial that same day.

Other countries, experts say, have figured this out. Isaac praised the clear, consistent health directives from leaders in New Zealand, which discharged its last hospitalized COVID-19 patient May 27. Marcus pointed to the Netherlands, where officials acknowledged that singles would still crave companionship and dispensed advice about how to safely navigate intimacy amid the pandemic. A straightforward campaign about avoiding the “three C’s” — closed spaces, crowded spaces and close contact — has been credited with helping Japan through the crisis.

So what’s making it harder for the U.S.? The politicization of the pandemic, harm reduction advocates said. That is not a new phenomenon for those who work in sex education or drug policy, which affect wide, diverse swaths of people but have turned into partisan fights, despite years of scientific research proving the effectiveness of harm reduction.

Now the same is happening with a crisis that affects every American.

• • •

Adding to that polarization, Marcus said, is a tendency to see anything short of condemning risky behavior as contributing to it — even though, for example, research has debunked the idea that needle exchange programs make people more likely to use drugs.

“We don’t like that irresponsible behavior, and we don’t want to promote it,” Marcus said. “It’s denying the reality that the behavior is happening.”

Harm reduction doesn’t have to be controversial, advocates are quick to mention.

Every day, for example, millions of Americans drive cars. Car crashes kill tens of thousands of people in the U.S. each year, but most aren’t calling for a carless society or for lawless, “Mad Max” highways. Seat belts and speed limits don’t prevent every crash, but they let us live in the risky middle.

“We do a whole bunch of things, and we require a bunch of things, to reduce harm,” Isaac said. “People accept that — I don’t drive like it’s the Autobahn through a school zone.”

Even once-polarizing measures of harm reduction have become more broadly accepted in recent years. Negron said the prevailing attitude toward drugs in Florida when she moved here from California in 2013 struck her as “the old ’80s tough-love paradigm.” In 2016, Florida voters overwhelmingly approved medical marijuana, and in 2019, the Legislature allowed the expansion of needle exchange programs.

Grove pointed out that an overwhelming majority of parents now support comprehensive sex ed, though it’s still not the norm in many places, including Pinellas County.

Such changes can take place when a crisis hits home, Negron said, gesturing toward conservative politicians who changed their thinking about needle exchanges when the opioid epidemic started ravaging their communities.

The key is “getting back to the personal level and really trying to tap into a person’s empathy,” Grove said. “Remember that there are tens of thousands of people that have already died. Imagine if that was your mother. Imagine if that was your child.”

What happens next? Maybe public health messaging improves and gets more consistent, mask-wearing becomes the norm and Americans learn how to live in a gray area. Or maybe the messaging stays diffuse, masks remain a symbol of political divide and America sinks deeper into polarization as we brace for a possible second wave.

The U.S. recently surpassed 100,000 coronavirus deaths. In that way, too, this pandemic is like other crises that have ravaged vulnerable Americans: If change comes, it will be on the heels of a massive toll.

“Drug policy is a good analogy,” Negron said. “It’s the same with sex education. It’s the same with the HIV crisis. After doing things wrong in almost every case, we turned to a different way that started to help people.”

• • •

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