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.