Shiny dark hair runs in the family. Photo by Juan Carlos Lara.

The latest lockdown to curb COVID-19 in California, announced at the beginning of December, was accompanied by pushback, but it is worth noting the nature of some of the protests. The backlash extended beyond those protesting restrictions on civil liberties and questioning the severity of the virus, and included rural workers, restaurant owners, parents, and lawmakers, many of whom have supported past measures.

Increasingly, a number of public health practitioners are encouraging policymakers to enact restrictions that are more chiseled, more nuanced, and more compassionate. They are arguing for a harm reduction approach, particularly around the holidays.

What do we mean by more chiseled, nuanced and compassionate? By chiseled, we mean that outright lockdowns should no longer be applied everywhere to curb COVID-19 transmission. Ten months into the pandemic, we know much more about the virus than we knew in the spring, when across-the-board lockdowns were applied.

We know that surfaces and fomites are not the primary mode of transmission. We know that the four non-pharmaceutical interventions – face masks, distancing, hand hygiene, and ventilation – massively mitigate COVID-19 risk.  We know that outdoors is much safer than indoors for gatherings; and we know that food insecurity, poverty, evictions, mobility, and business loss influence health outcomes.

Therefore, policymakers should restrict activities inside, but not outside universally. If closing these venues, they should provide data on the risk of outside activities where all four non-pharmaceutical interventions are applied.  And, as the governor and city finally did, they should consider the impact on closing outside playgrounds on low-income families without access to other outside play spaces.  

By nuanced, we mean without extremism. It is possible that anti-science conspiracies, COVID-19 denialism, and President Trump’s failure to support an effective federal response and personally flout public health recommendations pushed scientists to take diametrically opposite positions to prove a point.  

Extremes like shutting down all businesses or stating only members of a single household can be together are not effective. Concern for the working class and for those with socioeconomic insecurity should be a large part of the discussion from public health practitioners this long into the pandemic. Otherwise it is extreme to discuss lockdowns and restrictions without taking these real-world socioeconomic conditions into account.

Complete lockdowns favor those who can work at home and are privileged to not have to go out of the house to work (e.g. those who work in technology sectors/finance). If the last vestige of a business is being closed by public health (e.g. outside dining for restaurants in California), economic provisions for the workers in those establishments should be announced simultaneously with the closures. When John Snow closed down the famous “cholera spreading” water pump in London in 1854, for example, he still allowed for access to water elsewhere.

Third, the failure to recognize the arbitrary nature of and non-data driven approach to some of the restrictions, along with the failure to recognize the mental health impacts of a seemingly endless pandemic is not compassionate. The desire to see loved ones is both real and human.  

Dr. Scott Morrow, public health officer for San Mateo County in the Bay Area, delivered an anguished 15-point letter to the population in his county on the latest surge in California, in which he acknowledged the importance of protecting the county from this surge, but also acknowledged that mental health effects and business loss will figure into his decisions.

State and local public health officials should follow suit and begin every restriction announcement by reiterating compassion for the public and with reassurance that all other possible avenues have been considered.

Finally, we suggest using harm reduction principles in our messaging for the winter holidays to avoid erosion of public health messaging. Harm reduction is the principle of advising people on how to minimize risk of a pathogen since abstinence-only approaches are often infeasible or, in some cases, counterproductive. Harm reduction takes the holistic circumstances of an individual and a population into account when providing messaging on mitigating risk.

Take holiday travel. The message to not travel for Thanksgiving was met with skepticism by some and outward defiance by others. Therefore, instead of demanding an abstinence from travel, messages should focus on asking people to stay home if possible but acknowledge the fact that some people will still travel and need to know how to do so safer. What might this look like?

Providing specific guidance on how to enact the four non-pharmaceutical interventions if they choose to see loved ones over the holiday. If feasible, meals and gift giving should occur outdoors. If not feasible, guests should wear masks except during meals and should then be seated in another room. People should be encouraged to limit contact before travel to minimize risk of exposure and should be provided resources regarding testing should they become symptomatic during travel.

Furthermore, airlines need to be flexible with rebooking and waive change fees for people who may have been exposed or are symptomatic. In essence, public health messages must include real solutions and real tools rather than appeals to abstain.

While there is hope now that distribution and administration of highly effective vaccines for COVID-19 has begun, messages about masks, distancing and limiting crowds will need to continue for a while longer until there is equitable and widespread distribution. Restoring and maintaining trust in public health messaging during this time is of utmost importance and requires self-examination by those doing the messaging.

This virus is real and its health effects can be severe and deadly; the pandemic must be taken seriously. Simultaneously, however, people are lonely, have experienced personal and financial loss, are increasingly facing food and housing insecurity, as well as depression, anxiety, and hopelessness. All of this matters. All of this is real. All of this is part of public health.

Let’s mitigate eroding trust in public health recommendations by employing nuanced and compassionate messaging as we enter what we all hope is the final stretch of the COVID-19 pandemic in 2021.

Dr. Monica Gandhi is a researcher and medical director of the HIV Clinic, Ward 86, at the University of California, San Francisco.

Dr. Joshua Barocas, is an assistant professor of Medicine at the Boston University School of Medicine and Infectious Diseases physician at Boston Medical Center.

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  1. Well said.

    It is important to take multiple perspectives on the crises.

    It reminds me of when I was a teenage intern for a pharmaceutical company back in the 80s, attended a lecture about vaccine uptake. I was incredulous that anyone wouldn’t get vaccines for their children — until the lexturer presented the history of the Tuskegee experiment and more.

    The lecturer then went on to make a very important point: People do not take health advice from people who, in other contexts, have wished them ill. Makes sense right? We instinctually do not take advice from outsiders who want us dead. When you are a mother in Pakistan and you read an op-ed from an American who wants to turn your homeland “into a sheet of glass,” you don’t hand your child over to an American health aid worker to swallow polio drops. When you look up a public health worker’s Twitter feed and see them write “I hope Trump supporters choke on their own vomit and die,” you are skeptical when you see that very same name on a byline recommending the vaccine for everyone in your nursing home, most of whom voted for Trump.

    There is plenty of blame to go around, but public health officials need to take some responsibility for their messages or they are going to lose all credibility. Apologize, then add nuance, and start getting more voices in the room.

  2. The “harm reduction” analogy does not hold up in this situation. It is one thing to tell an addict to modulate their behavior so as to reduce the harm to themselves. It is an entirely different thing to tell the public to modulate their behavior so as to modulate the harm to everybody else. This article is not worthy of Mission Local.

  3. Just how much hand-holding does this duo think officials should be doing to make nicey-nice with the public so they’ll all behave themselves?? Neither of these doctors is on the front line right now, working in hospital ICUs, dealing with the deadly fallout of people who refused to listen to sense about staying at home rather than traveling for Thanksgiving! They have a nerve in claiming that frontline medical workers or public health officials should be doing more, while so many people are flouting the common-sense Covid guidance! The Covid virus doesn’t care if you’re lonely, or you want to go out to eat, or you want to feel free to carry on living as if there’s no deadly viral pandemic happening out there. Harm reduction IS what officials are doing by closing all but essential businesses… They should honestly be closing non-essential shops, too, using tracing to track the virus spread, and fining people who repeatedly violate the rules. This isn’t fun, it isn’t meant to be easy. It’s meant to save lives, and the longer it’s drawn out by people flouting the rules, or people like the authors, who promote a dangerous “let’s try to find a compromise” strategy, the longer people have to deal with shutdowns, losing their jobs, and having financial difficulties. This article is opinion, NOT science, and the authors will have blood on their hands for having used their medical titles to promote this poor public health policy perspective. The best way to prevent mass casualties in hospitals around the country in the new year is to stay home now. No one HAS to gather for Christmas, and choosing to do so can be deadly, including for those who didn’t choose to go out unnecessarily and expose themselves to Covid. Behave like rational adults, take some personal responsibility for your actions, and stop letting irresponsible pandemic-apologists like these two convince you that it’s okay to ignore the reality of this potentially deadly situation.

    1. I completely understand what you’re saying, but I feel you’re missing the entire point the op-ed is making.

      In a perfect world, every single one of us would stay home for a month and the virus would be defeated. Hell, we could even plan it — a month’s food delivered to every home, no one, at all, allowed to leave.

      But we don’t live in a perfect world. Humans are social animals. Solitary confinement is considered a human rights abuse. And while yes, the majority of us are able to socialize via phones and the internet, it’s absolutely not the same, and any therapist can explain why for reasons well before this year.

      We’re 9 months into this. The coldness has hit us all. I personally haven’t seen my partner in 10 months because it would require travel, and it’s *hard*. I’ve been able to see my elderly mother who lives in the city only a handful of times, in parks, but not in a month.

      What frustrates me beyond belief, is the restrictions that penalize harm reduction, exactly as this piece argues. You can’t outright ban humans socializing, and yet that’s what they’ve done. So instead, they pushed it inside, because you can no longer meet in a park. You can no longer have a meal outside, at a restaurant. Go take a walk this evening, around 6pm, and watch how many people are on their way to dinner parties.

      I feel there are some truly awful comparisons with all this with the drug wars. Banning drugs and criminalizing users only exacerbated loss of life. So does criminalizing socialization. People will still gather, but now they’ll do it mostly inside. Harm reduction is compassionate, and acknowledges the realities of the human condition.

      I’ll mutter at the people hosting dinner parties too, for the record. But I get why they are. I just want my muttering to be that they didn’t meet their friends, or family, in a park or even an outdoor restaurant instead. Safer places, even if not perfect.

      It’s truly insane I’m banned from seeing my mother, or a friend, six feet apart, masks on, in a park.

    2. Harm reduction is important because abstinence has been proven to be a public-health failure. Everyone I’ve talked to is having an indoors Christmas get-together with people from other households, yet the government and public health officials are acting like this isn’t happening (remind you of when your parents turned a blind eye to you having teenage sex?). Why not provide guidelines for safe holiday mixing with one other household, like Germany does? Or for having a “seksbuddy,” like the Netherlands does? Those of us who are really concerned are staying home alone for the next month or two, until the Covid numbers decrease, but we seem to be in the minority. Public-health officials owe it to citizens to help them understand how they can see their loved ones safely.

  4. We know that outdoor dining involves people sitting much closer than 6 feet apart, unmasked.

    We know that this increases the likelihood of COVID-19 transmission.

    You know that there is too much community spread right now to adequately contact trace dining environments. How do you expect to get hard data about this specific activity, and why do you care, when you know there is a wide and growing percentage of the population that has the disease, and outdoor dining involves two factors known to spread the disease — close contact, and non-masking.

    Given that your interests are all HIV related:
    “pre-exposure prophylaxis (PrEP)
    HIV infection
    education
    adherence measures
    mentoring
    HIV infection in women
    hair concentrations of antiretrovirals”
    maybe you should stay in your lane?

    https://profiles.ucsf.edu/monica.gandhi

  5. By far, my favorite piece in Mission Local this year! This type of discussion is sorely missing from ‘mainstream media’ channels.

  6. “We know that the four non-pharmaceutical interventions – face masks, distancing, hand hygiene, and ventilation – massively mitigate COVID-19 risk.”

    Masks offer up MODEST, not massive, protections from transmission. We should all wear masks when indoors and near others. But let’s not oversell them. Odds are that when the weather turned and more people crowded indoors, that was the instigation for the spike, even when masked.

    We’ve seen spikes starting in early November across jurisdictions with a range of face covering public health orders, political party rule and regions. This is much more complex and nuanced than simply bleating “wear your damn mask.”

    But public heath messaging is as much psychology as it is biology. I do not envy the SF DPH as they to juggle these competing priorities, especially when the federal, state and local governments run by both parties have decreed that we’re all on our own economically when it comes to our needs.

  7. “It is possible that anti-science conspiracies, COVID-19 denialism, and President Trump’s failure to support an effective federal response and personally flout public health recommendations pushed scientists to take diametrically opposite positions to prove a point. ”

    That is an extraordinarily corrosive thing to say broadly about the scientific and research communities. That is accusing the scientific community of the same politically motivated twisting of the science that the current administration is using to discredit that very science. From the perspective of an AIDS survivor and activist, I find this shameful especially for the medical director of Ward 86 where I have been a patient for 3 decades and generally have held in high regard.

    1. I think one thing we’ve learned over the course of the last nine months is that public health is inextricably tangled up with politics in a broad sense as well as narrow. How can it be otherwise when choices have to be made, choices which come with costs and benefits? Remember also that for the past four decades, the public sector, including public health, has been intentionally defunded and degraded. This was a political decision (see Margaret Thatcher in the current season of “The Crown”). Though in some cases, choices have been constricted by finances, but that also implies a political decision. For example, local officials could have chosen to pour far more resources into testing-tracing-quarantine programs in the Latinx community and the Southeast neighborhoods of the City. Their failure to do so was not a moral or financial decision, much less a scientific one, but was political in its very essence. The political dimension of public health becomes quite pronounced in what we call “messaging” or “communication”, public relations, an area which does not get enough attention, and in which scientists, researchers and public health officials rarely have much training. Did some public health officials react to Trump? Undoubtedly. Check out Dr. Robert Redfield’s testimony in front of Congress this past summer when he asserted that universal masking would eliminate the threat of the virus in less than two months. Finally, as we also learned this year, “science” can serve different goals, and data can be interpreted in a variety of ways. To say I disagree with Scott Atlas and the “herd immunity” gang at the Hoover Institution doesn’t mean I consider them “anti-science” — it means we have different political positions and goals.

    2. John, if anything, I’d say the opposite is true. I became more and more galvanized in my COVID-skeptical stance the more I saw scientists and public officials being severe, unhopeful, and unwilling to consider any positive news that ran counter to the narrative that this was the worst thing ever to happen on earth. If there had been an iota of perspective instead of a broad shutdown of discussion, I would probably have been a team player all along.

    3. @Broyles: That’s rich. What I find most fascinating about this is that San Franciscans who I would expect to be critical thinkers on some level, (I mean they are more educated right?) Would be the first to denounce anti-vaccine people and climate change denialists as “anti -science,” yet they have just rolled over and accepted the restrictive Covid measures without any call for evidence. I’m super proud of the Southern California Restaurant owners who pushed back on the outdoor dining restrictions and the judges who have supported them, insisting that public
      health officials show their data.

      Broyles I am also a survivor of the last pandemic, HIV, and if I learned one thing it’s to question everything and everyone : Including public health officials and scientists. And I would add that many of us found our way through that pandemic through harm reduction approaches that courageous scientists like Gandhi and Julia Marcus from Harvard are advocating for this crisis.