Harm reduction principles can help us restore trust in public health messaging on covid-19

Public health messaging should acknowledge the holistic experiences of individuals beyond just the pathogen, say Joshua Barocas and Monica Gandhi

Public distrust in healthcare and public health experts is growing, according to a recent report in the Chicago Booth Review—a conclusion that is borne out by the protests to the latest lockdown in California across multiple sectors. While there are many external forces at play in this distrust, we as a healthcare community must also look inward. At times, healthcare and public health practitioners have strayed from the core values of public health when communicating covid-19 prevention strategies. This deviation may be partially to blame for some of the public’s distrust and the US’s lack of progress in controlling the covid-19 pandemic. 

Public health and scientific messengers must evolve non-judgmental, holistic, and patient focused styles of messaging around risk reduction and disease prevention. Returning to our discipline’s basic principles and centering our approach around reducing harm may help restore trust in public health.

Harm reduction—when applied to disease prevention for infectious diseases—is the principle of advising individuals how to mitigate risk, while acknowledging the real world conditions that may lead individuals to take some risks. HIV doctors and addiction health specialists are well versed in harm reduction principles; we would have lost patients a long time ago if we yelled at them to “wear a condom, stupid” or failed to recognize the lived experiences of individuals navigating intimacy, loss, love, and personal trauma in light of the risk of or infection with a virus. 

Trust between patient and doctor and between a public health system and an at-risk populace starts with messaging that acknowledges the holistic experiences of individuals in a population beyond just the pathogen. As HIV doctors, we have been struck by how far some have strayed from core public health principles in the messaging around covid-19 prevention.

The core tenet of medicine is to do no harm. In public health, it is to promote equity, civility, and justice. And in scientific research, it is the unbiased pursuit of fundamental truths through the scientific method. Universal to all of these professions, whether doctoring, public health, or basic science, are other fundamental principles. Trust but verify. Consider the implications of the work. Endeavor to make life better and worth living for others.

One need not look further than the top of a Twitter feed or on cable news to see deviations from these core values by some scientists during these unprecedented times. These individual and collective actions might be harmful to efforts to control the transmission of the virus. To make progress in this pandemic, it seems prudent to ask what it means to have strayed, how this point was reached, and how to find the way back.

So, what do we mean when we talk about there being a divergence from public health’s core values? Firstly, some public health messengers have demonstrated limited respect for others in their social media interactions. Twitter hashtags posted or retweeted by healthcare professionals, public health experts, and other scientists include #LetThemDie and #COVIDIOTS. Americans who do not wear a mask or practice social distancing have been called “morons,” “stupid,” and “selfish” by some scientists. Some physicians have even questioned publicly whether they are obligated to treat someone with covid-19 who doesn’t wear a mask or follow public health restrictions.

Secondly, the scientific process has been truncated by our greater reliance on preprint publications and the sharing of information through media, social or otherwise. Early in the pandemic, preprint publications were crucial to disseminating information rapidly about this virtually unknown virus. Nearly a year into the pandemic, preprint material continues to disseminate data, some of which does not go on to withstand peer review. In some cases, this rapid circulation in the wider community of data that haven’t been peer reviewed causes more harm than good.

Finally, some have claimed expertise when they should not. Titles alone of “doctor” or “epidemiologist” or “researcher” do not confer all knowing expertise in disasters, infectious diseases, or virology. The under-informed opinions of non-experts have made the unbiased pursuit of fundamental truths more difficult and have undermined public trust. Social media can amplify such opinions and reward judgmental messaging.

How did this occur since, optimistically, most individuals in public health and health sciences are motivated by the desire to do good? Firstly, the silencing of international experts under the outgoing presidential administration in the US left us without a unifying goal. Much like an orchestra without a conductor, scientists across disciplines vied for control. This led to a disjointed approach rather than well constructed harmony. Secondly, many felt the need to thwart the constant stream of misinformation and conspiracy theories from many sectors. At first, yelling seemed necessary just to be heard, but as the misinformation has become more absurd, so have the responses become more extreme. Finally, after nearly a year of this pandemic, with infection rates now reaching new highs countrywide, disinhibition and exhaustion have set in, leading to brash comments and a lack of empathy. Some of the recent messaging urging the public to stay home for the holidays, for example, could seem unsympathetic to loneliness and would have benefitted from a different, kinder approach. 

The question remains: how to find our way back? New leadership in the US and global cooperation should serve as a compass. But according to a recent poll, politicians are not considered credible messengers about the pandemic. Therefore, the voices of scientists and medical and public health leaders are crucial.

These voices should incorporate principles of harm reduction. HIV and addiction medicine specialists acknowledge the ongoing risks from sexual activity and substance use, but advise on ways to keep safe. Primary care doctors and cardiologists speak of “lowering your risk” with regard to heart disease and diabetes, recognizing that people will still eat unhealthy food. Public health practitioners and scientists offer messages of “caution” when interpreting their findings since they may not be widely applicable or generalizable. In each of these examples, whether as providers with patients, as public health practitioners with an at-risk populace, or as scientists with the non-scientific community, messages should acknowledge the holistic experiences of individuals. Moreover, scientists should accept that their knowledge is finite and often limited or biased by their own experiences.

Such a framework can be applied to our covid-19 messaging. Providers should find out why their patient does not want to wear a mask and find situations in which they might (e.g., grocery stores). Public health practitioners must develop messages that deeply sympathize with the lived experiences of those trying to do the “right thing,” but tiring of restrictions. Messaging that accuses people of being irresponsible, instead of acknowledging how they may be exhausted, lonely, and confused by restrictions, is not the way to gain public buy-in. Small gatherings to socialize outside with the four non-pharmaceutical interventions (masks, distancing, hand hygiene, and ventilation) should be emphasized as safer ways to reduce risk to avoid driving people indoors to socialize.

Finally, information should be messaged in a way that is accessible to the public. For all, we must try to understand the misery, loneliness, and isolation that can accompany current public health dictums, and accordingly communicate with kindness and understanding. This long into a pandemic, incentivized messaging may work better than fear based messaging. A clause to a business of “we are going into lockdown” should be followed by a second clause of “and this is how we are going to support you during this time.” The outrage generated by government officials not following public health guidelines that they set may be triggered partially by a failure to acknowledge that all of humanity is longing to gather again. Messaging clearly why restrictions are in place, which restrictions make sense by the science, and when they are expected to end with widespread vaccination will help regenerate trust in public health messaging.

This path of harm reduction is not a new one. We have learnt a lot from our experiences from the HIV and overdose epidemics, and these lessons on messaging can be used to inform the current pandemic. As the world turns its eyes, with hope, to the SARS-CoV-2 vaccine candidates, scientists have a lot of communicating still left to do. Healthcare professionals and scientists must return to our guiding principles in order to regain the trust of the public and turn this tide.

Joshua Barocas is an infectious diseases physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine. Twitter @jabarocas

Monica Gandhi is an infectious diseases physician at San Francisco General Hospital and a professor of medicine at UCSF. Twitter @MonicaGandhi9

Competing interests: None declared.