Society Will Never Be Free of COVID-19—It’s Time to Embrace Harm Reduction

Sep 1, 2021 by

Policymakers should accept the fact that COVID-19 will become endemic and adopt the vision of the harm reduction movement that grew up in response to the crisis created by drug prohibition.

By Jeffrey A. Singer

The COVID-19 virus will not be eradicated. The only human virus ever to be eradicated was smallpox, and that took 200 years. COVID-19 will become endemic. It likely will continue mutating and developing variants.

But we’ve learned a great deal about the virus since the pandemic began. Unlike smallpox, which had a 30 percent fatality rate; or Ebola, which has a 50 percent fatality rate; or respiratory syncytial virus (RSV), which has up to a 1.7 percent fatality rate in children and over an 11 percent fatality rate in adults, COVID-19 appears to average a 0.3 to 0.4 percent infection fatality rate in Europe and the Americas and a 0.2 percent fatality rate among people not living in institutions. In the United States, 80 percent of fatalities have occurred in people over age 65, and 39 percent of all COVID-19 deaths in 2020 occurred in nursing homes. As of July 29, 2021, 358 U.S. children under age 17 had died from COVID-19 since the start of the pandemic. (For comparison, the average annual fatality rate for RSV in children is 500.) Martin A. Makary, a public health professor, and his team at Johns Hopkins University found that most of the children who died of COVID-19 had preexisting vulnerabilities such as leukemia. This tells us which populations need the most protection.

COVID-19 is not the only endemic problem in public health. For example, obesity is an endemic problem that leads to diabetes and cardiovascular disease. Sexually transmitted diseases and teen pregnancy are endemic. And the epidemics of HIV, hepatitis, and overdoses due to the use of illicit substances are never‐​ending. Unlike the COVID-19 viral pandemic, which can affect any human in its path, these other conditions usually involve lifestyle choices. But what they all have in common is that we will never be able to eradicate them completely, and efforts to address them get bogged down by politicizing and moralizing. Zero‐​tolerance approaches to all these problems are not only destined to fail, but they cause more harm than good.

A zero‐​tolerance policy toward illicit drug use causes harms to many facets of society, well beyond the harms that result from using tainted black‐​market drugs. Likewise, a zero‐​tolerance policy toward COVID-19 carries tradeoffs involving mental and physical health, education, economic well‐​being, wealth disparity, and societal integrity, well beyond the harms of COVID-19. Accepting the fact that we will never have a drug‐​free society, Congress and the Biden administration are showing a renewed appreciation for harm reduction strategies to address illicit drug use. These strategies aim at making illicit drug use less likely to spread death and disease while accepting that there will always be people who use illicit drugs. Public health officials and policymakers need to accept that we will never have a COVID‐​free society. There will always be new variants and occasional outbreaks. They should pivot to harm reduction strategies to address the COVID-19 pandemic to allow life to go on, as “normal” as possible, in a world where COVID-19 is endemic.

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Jeffrey A. Singer discusses how solely focusing on COVID-19 is hurting other patients on the Reason podcast

Almost two years since the start of the COVID-19 pandemic, governments around the world still grapple with the virus. In the United States, in fits and starts, states impose varying restrictions on economic activity, in‐​person learning, social gatherings, and recreational activities. Yet as of mid‐​August 2021, the Delta variant of COVID-19 rages across the country like a brushfire, primarily infecting unvaccinated people. A recent National Bureau of Economic Research working paper shows that the effect of mobility and crowd restrictions, such as shelter‐​in‐​place (SIP) orders, “on public health are a priori ambiguous as they might have unintended adverse effects on health. The effect of SIP policies on COVID-19 transmission and physical mobility is mixed.”

Fueling further uncertainty, a recent study ranked New Jersey, New York, and Massachusetts among the states that enacted the most stringent restrictions. Yet these states were ranked first, second, and third, respectively, among the states in per capita fatalities. Iowa, the state with the least stringent restrictions, ranked 19th in per capita fatalities. Florida, ranked second to lowest in restrictions, was 26th in per capita fatalities. California, ranked sixth in stringency, relaxed restrictions in late June 2021 only to see a surge in cases of the Delta variant beginning in late July and accelerating in early August. As of July 30, more than 90 percent of the new cases were among the unvaccinated and, while hospitalization rates were rising, the increases were much less than were seen during the winter of 2021 and were greater in states with lower vaccination rates.

Overseas, Australia provides an extreme example of the failure of zero tolerance. Attempting to take advantage of its island status to isolate its people from the virus, Australia has virtually banned travel to or from the continent since March 2020, with strict quotas on re‐​entering even for Australian citizens. As of the end of June 2021, 34,000 Australians were still stranded overseas. The government has imposed numerous stay‐​at‐​home orders on its people since the pandemic began (Melbourne began its sixth stay‐​at‐​home order August 5). Yet three weeks after the government issued a stay‐​at‐​home order to the millions of residents of Sydney and New South Wales, enforced by soldiers going door to door to check on compliance, Australia suffered its worst spike in COVID-19 cases.

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Harm Reduction

The first use of the term “harm reduction” came from a movement that began in Liverpool, England, in the early 1980s that was led by a group of doctors, nurses, and activists seeking to reduce the spread of HIV from needle sharing among intravenous drug users and to stabilize the lives of people with substance use disorder. It has since gained wide acceptance in much of the developed world, although it has been slower to take hold in the United States. Strategies include syringe services programs that provide clean needles and syringes, fentanyl test strips to check for its presence in illegally bought drugs, bleach and other equipment for users to clean their paraphernalia, and the overdose antidote naloxone. Safe consumption sites offer even more comprehensive services in Europe, Canada, and Australia but are federally prohibited in the United States.

Other harm reduction strategies include “safe supply,” where pharmaceutical‐​grade narcotics and stimulants are prescribed to people with addiction to substitute for dangerous black‐​market drugs, and medication‐​assisted treatment using drugs such as methadone and buprenorphine to help patients stabilize their lives while avoiding the horrors of withdrawal. More than 30 years of data support the effectiveness of these strategies in reducing drug overdoses and the spread of HIV and hepatitis, explaining the growing acceptance of harm reduction throughout the world.

Health care professionals readily grasp the idea of harm reduction. In developed and affluent societies, much of what health care practitioners do is engage in harm reduction. Statin drugs and antihypertensives are prescribed to overweight and sedentary patients to reduce the risk of the lifestyles that they are unable or unwilling to change. Doctors engage in harm reduction when they prescribe drugs like metformin to mild diabetic patients who might not need the drug if they adhered to a better diet. Realizing an abstinence‐​only approach won’t work well to reduce the spread of sexually transmitted diseases and unwanted teen pregnancies, health care practitioners recommend condoms and hormonal contraceptives. In fact, while well‐​marketed by drug rehabilitation centers, the abstinence‐​only approach to treating substance use disorder is less effective than harm reduction. Recent research has found medication‐​assisted treatment for opioid use disorder with methadone or buprenorphine to be the only approach yielding reduced overdoses or opioid‐​related morbidity.

Harm Reduction as a Strategy for COVID-19

A harm reduction approach to the COVID-19 pandemic engages strategies such as vaccination, face masks, maintaining adequate bed capacity in hospitals, surface cleaning and handwashing, social distancing, and adequate ventilation.

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Harm Reduction as a Public Health Strategy for Pandemics


Fortunately for the United States and other developed nations, most adults are choosing to get vaccinated against COVID-19. The two mRNA vaccines (made by Pfizer and Moderna) and the single‐​dose adenovirus‐​based vaccine (made by Johnson and Johnson) being used in the United States have proven highly effective against severe illness leading to hospitalization or death even from the Delta variant. For the overwhelming majority of people who have been vaccinated, the threat of a COVID-19 infection has been reduced to the threat of a mild to moderate cold.

Add to the population with vaccine‐​induced immunity those who have acquired immunity as the result of infection, so‐​called natural immunity. Several studies show that natural immunity might be longer‐​lasting and broader‐​based than vaccine‐​induced immunity.

When viruses replicate, mutations lead to the development of new variants and the risk that one might evade people’s immune defenses. As more of the population attains either vaccine‐​induced or natural immunity, fewer pathways remain for the virus to replicate and spread. This ultimately leads to fewer and smaller outbreaks. It also means fewer chances for new variants to emerge. But there will always be new variants on the horizon. A lambda variant has been on the move in South America. It is also possible, but uncertain, that the virus might eventually evolve to a less deadly—if more contagious—form.

The vaccines do not provide complete protection from infection. But they provide extremely powerful protection from serious illness requiring hospitalization and nearly complete protection from death. While many non‐​pharmaceutical interventions aimed at containing the virus have had spotty and disappointing results, vaccines have proven to be the most effective tool in the COVID-19 harm reduction tool chest.

While vaccines are clearly advisable, state‐​mandated vaccination should be avoided. It is impossible to know if an unvaccinated person will become infected and spread the virus to others. There is no certainty that forcibly vaccinating someone won’t cause that person serious or even life‐​threatening harm. With COVID-19 downgraded to the status of a common respiratory virus for those who choose to get vaccinated, vaccinated people are less threatened by those who pass up the vaccine.

On the other hand, neither is it justifiable for the state to prohibit private organizations, businesses, or workplaces from requiring customers, clients, or employees to get vaccinated. These are voluntary associations. Just as places of business have the right to state, “no shirt, no shoes, no service,” they have the right to add “no vax” to the list of conditions. For certain industries, such as the hospitality industry, it may make good business sense to do so.

It certainly makes good sense for hospitals, nursing homes, and other institutions, where personnel may contract and spread COVID-19, to require staff to get vaccinated. And that policy is consistent with the already commonplace hospital and nursing home requirements that their staff get annual flu vaccinations and tuberculosis screening skin tests.

Mask Mandates

Most recommendations about wearing masks seem to make sense intuitively but thus far are not strongly supported by the evidence. There have been few randomized controlled studies on mask efficacy. The first peer‐​reviewed randomized controlled trial was published in March 2021 involving 3,030 Danish participants during April and May 2020. The study failed to demonstrate any evidence that mask‐​wearing reduced the SARS‐​CoV‐​2 infection rate, although the study had several limitations.

The type of mask matters as well. Mechanistic studies have been performed on the penetrability of virus particles by mask type. They show that cloth masks provide protection that is barely better than not wearing a mask at all. Surgical masks provide slightly better protection than cloth masks. Fully‐​fitted N95 masks offer good protection for about 25 hours—unfitted N95 for 2.5 hours.

There is no evidence of the need to wear masks outdoors in uncrowded situations. To date only one retrospective study has been conducted to see if masks reduced COVID-19 transmission in grade‐​school children, and it was inconclusive. Some pediatricians worry that masks mute nonverbal communication and may inhibit the development of language and communication and other social skills in very young children.

As Cato Institute scholar Ryan Bourne points out, the context for the indoor masking debate has changed dramatically in recent months. In the United States, as of mid‐​August, roughly 90 percent of the most vulnerable population—those over age 65—had been vaccinated. Close to 60 percent of the eligible U.S. population was fully vaccinated by the beginning of August 2021. (A small percentage of immunocompromised patients have not developed adequate immunity from the vaccines, and the Centers for Disease Control and Prevention [CDC] recommends that they be given a third dose of mRNA vaccine.) On August 18, the CDC announced that beginning in late September, it will make boosters available to people who received their second dose of mRNA vaccines eight months earlier and that it expects to offer boosters to those who received the single‐​dose Johnson and Johnson vaccine in a few months. And vaccines are readily available, free of charge, for anyone over age 12. At this point, whatever risk vaccinated yet asymptomatically infected people pose of transmitting the virus to others, those who choose to remain unvaccinated have accepted the risk. Requiring vaccinated people to wear a mask indoors asks vaccinated people to protect unvaccinated people from themselves. Furthermore, it discourages people who are hesitant to get the vaccine from getting vaccinated by signaling that the vaccine is not efficacious enough to allow people to go without masks.

On July 27, the CDC issued new guidelines stipulating that all people, vaccinated and unvaccinated, should wear masks indoors, based on a report from Provincetown, Massachusetts, where, after a week when 60,000 people attended “Bear Week” in tightly packed indoor spaces, there were 469 cases of COVID-19 reported. Provincetown has a 95 percent vaccination rate, and the surrounding county has a 69 percent vaccination rate. Seventy‐​four percent of the 469 infected people were previously vaccinated, but with such a high vaccination rate, that should come as no surprise. The startling percentage of “breakthrough” infections is the result of what statisticians call rate bias. The study was further limited by the fact that all cases were self‐​reported. More important: only five people were hospitalized, four of whom were vaccinated, and there were no deaths.

The CDC was concerned that concentrations of viral nucleotides in the nasal passages of those with breakthrough infections approximated concentrations seen in unvaccinated people. The CDC feared that this means that people with breakthrough infections can “shed” viruses as readily as unvaccinated people with infections. But this is simply bad science. Nucleotides are not necessarily live, viable, transmitted viruses. A larger study from Singapore, and an even larger randomized study from the UK, both released after the CDC recommendation, found viral titers rapidly decreasing in people with breakthrough infections compared to unvaccinated people. Thus, based on very suspect data, the CDC undermined its own argument urging vaccination by implying the vaccines are less effective than they are.

Because of the insufficient data on the efficacy of masking and the possibility that mask mandates may discourage people from getting vaccinated, cause a false sense of security among mask wearers, and promote distrust of public health pronouncements, policymakers should avoid blanket one‐​size‐​fits all mask mandates. They should instead defer to local businesses, organizations, institutions, and individuals.

Unvaccinated people should wear masks in crowded indoor settings unless they are aware of the vaccination or health status of all involved. Vulnerable individuals, such as those who are elderly or immunocompromised, should be advised to wear masks in indoor public places. In both cases masks by no means offer bulletproof protection. But they help somewhat.

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Jeffrey A. Singer discusses the CDC’s about-face on mask guidelines and the FDA approval process for COVID vaccines on Sinclair Broadcast Group’s The National Desk

Maintaining Hospital Bed Capacity

During the first wave of the pandemic many state governors issued blanket statewide moratoria on elective procedures to reduce hospital crowding. The result, in many cases, was empty hospitals and personnel layoffs. Worse, the moratoria delayed essential treatment and preventive health services to thousands of patients.

In previous viral outbreaks, hospital administrators provided daily updates about their patient census and capacity, informing providers of their ability to handle elective procedures. As hospitals in different regions of a state saw a surge in flu patients abate at different rates, each would inform their medical staff about liberalizing elective procedures accordingly.

Statewide bans are less flexible. Maneuvering them can be like turning a battleship around. Decisions about lifting the bans are influenced by political as well as public health factors. Fear of public criticism fuels a tendency for politicians to be overly cautious. Bans are lifted across the board as opposed to being individualized and locally calibrated.

Governors should defer to hospitals working in conjunction with community health care providers and their medical staffs to make necessary adjustments in the services that they provide based on local knowledge in real time. One‐​size‐​fits‐​all moratoria don’t reduce harm but create more harm.

Surface Cleaning, Hand Washing, Social Distancing, Ventilation

Schools and public accommodations should not waste time with what often amounts to hygiene theater. Repeatedly disinfecting surfaces is not necessary to reduce COVID-19 transmission. The CDC reports scant evidence of viral transmission on surfaces and recommends general cleaning of surfaces with soap and water on an as‐​needed basis. While it is always a good idea to have clean surfaces to reduce the risk of infectious diseases, the only time it is necessary to use a disinfectant is if the surface was near someone with active infection during the previous 24 hours.

Handwashing after shaking hands or touching unclean surfaces is a good way to reduce transmission of viruses and bacteria and is always a good form of harm reduction. Handshaking can be a means of transmitting COVID-19 and other viruses if one of the participants is infected. However, it is not necessary to wear surgical gloves unless providing care to an infected person or disinfecting areas that an infected person has contacted. One concern is that wearing gloves may block the normal triggers to hand washing, paradoxically causing a greater risk for contamination.

The science is still unsettled on the distance required for protection from viral droplets. In some countries, public health officials recommend three feet. The United States and others recommend six feet. Much depends on ventilation, whether people are indoors or outdoors, whether the air is stagnant or moving, and the length of time of social contact. A good rule of thumb is to use good judgment to keep your distance and minimize “face time” with strangers who might be contagious. Adequate ventilation is always important for reducing airborne pathogens. When indoors without adequate ventilation or air filtration, consider opening the windows to promote recirculation with outdoor air.

Instead of advising the public to engage in expensive, unnecessary, and wasteful activities, public health officials should be telling individuals some basic things that they can do to really reduce harm: people with symptoms of a respiratory infection, vaccinated or unvaccinated, should stay the hell away. They shouldn’t visit vulnerable friends or relatives. They should cancel social plans. They should call in sick for work. They should get tested and stay home until recovered. Employers should insist that sick employees stay home. This should be a golden rule regardless of COVID-19.


Blanket one‐​size‐​fits‐​all mandates on human movement, behavior, economic activity, social, and educational arrangements have not “defeated” the virus. Many of these directives are unsupported by clear‐​cut evidence. Nor are they consistently applied. They often involve tradeoffs with harms greater than any benefits brought in terms of reduced risk.

Policymakers should accept the fact that COVID-19 will become endemic and adopt the vision of the harm reduction movement that grew up in response to the crisis created by drug prohibition. The most effective COVID-19 harm reduction strategy is to promote immunization. Public health officials should provide solid, regularly updated information to allow individuals and local jurisdictions to implement harm reduction strategies suited to their contexts so that they can pursue happiness and enjoy meaningful lives in a world that will always include COVID-19.

Source: Society Will Never Be Free of COVID-19—It’s Time to Embrace Harm Reduction | Cato Institute

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