Brooke Gladstone: In the pandemic's early stages, politicians and public health officials maintained the best way to prevent the spread was to stay home. Technically, that's sound advice. The only sure-fire way to prevent getting sick is to eliminate contact with all possible vectors but then reality set in. What good is good advice if it's nearly impossible to heed, especially over the long haul? Soon people began popping their quarantine bubbles and coming into contact with people they didn't live with. All that worsened by the fact that, stay home, left the public without the necessary tools to manage their own risk.
Needless to say because doubtless you know, the curve is no longer flattened. It's taken a sharp upward turn again. Epidemiologist, Julia Marcus is an HIV/AIDS specialist and assistant professor at Harvard Medical School. She's frustrated by the opportunities for public education missed by the CDC.
Julia Marcus: I think the CDC has sadly been rendered fairly impotent in this pandemic response. There are mistakes that have been made by the CDC but I ultimately think they have not been allowed to fully do their job. Even last week when they released some new practical guidance for people, they never told the public. Now the guidance is buried on their website. They have allowed themselves, I think, to be swayed by the White House. For example, in their most recent guidance on group gatherings, that very noticeably did not differentiate between indoor and outdoor gatherings and it was just before the Trump rally. I don't think it's an accident. I also don't think it's an accident that their guidance provided no information about sex or dating.
Brooke Gladstone: The CDC has become a little more focused on practical concerns over the last few weeks as cities reopen and has offered more options for social interaction.
Julia Marcus: First I'll say, it would have been helpful to have that guidance earlier when people were already making decisions every day about whether and how to engage in social contact with other people but better late than never, for example, trying to socialize outdoors rather than indoors, just practical suggestions that are based on the accumulating scientific evidence about viral transmission and also that acknowledged that people are no longer staying home. Now places are reopening to some extent.
Brooke Gladstone: Other countries handled this differently from the start, offering more options, seemingly trusting their citizenry to do the thing or to be able to handle some nuanced information or wasn't in the Netherlands, find a pandemic sex partner, whatever. Can you contrast the approach to the public?
Julia Marcus: Some other countries are historically more willing than the US to acknowledge basic human needs as part of public health guidance. Rather than just saying, "Here's the safest thing you can do which is to stay home," instead, some other countries including some Canadian provinces and as you said, the Netherlands, have adopted more of a harm reduction approach that accepts that people will take risks and gives them guidance on the safest way to go about it.
For example, if you are going to seek out social contact outside of your household, the safest way to do that is to keep your contacts as few as possible by creating a social bubble that remains consistent over time. Same thing for sexual contact, minimizing the number of sexual contacts. It accepts that people will seek out sexual contact but it gives them guidance on the safest way to go about it.
Brooke Gladstone: You mentioned harm reduction. Contrast that with what is frequently America's first choice, which is abstinence, when it comes to confronting a threat.
Julia Marcus: We know from research on HIV and safer sex, teen pregnancy, and drug use, that just say no, is not an effective public health message. That's essentially the message that we were getting in March and April. It was, just say no to social contact, just say no to leaving your house. Something like that can really work in the short-term but in the long-term, it doesn't recognize the realities of human behavior and human needs.
When we think about abstinence-only education for teens, we can actually see how that makes things worse. When we say, "Just don't have sex," and we're not going to tell you anything about what happens when you do have sex, we're just going to tell you not to have it, then the kids who do decide to have sex, and some inevitably will, lack the tools that they need to prevent pregnancy, to prevent STIs, to prevent HIV. That's why we see worse health outcomes with abstinence-only messaging.
Brooke Gladstone: Do you think that moralism gets in the way of public health? I was thinking of your experience with PrEP, which if taken daily, prevents HIV infection.
Julia Marcus: I see a lot of parallels between HIV prevention and what we're handling now, the coronavirus. Of course, they're very different viruses but I think there are lessons that we can learn. When we look at PrEP and, in general, HIV prevention, we see a lot of moralizing about, for example, condomless sex, about irresponsible behavior, reckless behavior, risky behavior and concerned that if we give people tools to protect themselves, that we will actually be promoting the risky behavior that we want to avoid.
There is some moral judgment there that ends up playing out in interactions between patients and healthcare providers. It makes people not want to disclose that let's say they are having condomless sex, then they don't get the HIV testing that they need, they don't get STI testing. People end up having worse health outcomes because of the stigma that they anticipate experiencing from healthcare providers. That's just one way that shaming and moralism plays out in public health. You can imagine in the current setting, if we shame and stigmatize "reckless behavior," not social distancing, not wearing masks, having a crowded house party. Even if that's something that we really do want to avoid when we moralize about it, it makes people afraid to disclose it.
What we're relying on for containing outbreaks is contact tracing as one strategy. That is built on trust and people's willingness to disclose. If somebody goes to a party and gets infected and we have to trace their contacts, if nobody will share that they were at that party, public health breaks down.
Brooke Gladstone: Of course, some people aren't ashamed. You specifically focused on the baseball player, Aubrey Huff, who made news last week for publicly refusing to wear a mask.
Aubrey Huff: I posted a tweet yesterday about no longer willing to comply for wearing a mask inside a grocery store. Now if you want to wear a mask and live in fear the rest of your life, it's certainly your prerogative, but the vast majority of well-adjusted, sane, common-sense people, that aren't sheep, they can reason for themselves, agree with me.
Brooke Gladstone: The internet seized on griping his anti-mask-attude. COVID shamed him, you could say, relentlessly. You say that even his concerns have to be taken seriously, right?
Julia Marcus: I would say that what we need to do is think about how to encourage mask use for everyone. In a way, his concerns are not the point. The point is centering the needs of the people around him. The question becomes what can we do to encourage mask use? Not just for an extreme case like Huff but more so for the majority of people who are genuinely trying to wear masks and sometimes just it doesn't quite happen. Like condom use, people are often well-intended, they have a condom sitting on their nightstand and they just don't end up using it and that's understandable.
Brooke Gladstone: Is it really?
Julia Marcus: I think we can always try to understand what the barriers are to the intervention that we want to promote and that when we start there, we become much more effective.
Brooke Gladstone: What would it look like to take a harm reduction approach to masks?
Julia Marcus: Part of harm reduction is literally meeting people where they are. We know where COVID has hit hardest and that's where we should start and not just the communities, the neighborhoods where it's hit hardest and mask access is lowest, but also the settings that are highest risk. I actually don't know that we need to be obsessing about mask use in parks, for example, and that's very visible. It's easy to fixate on that. What really is going to matter most, based on the available science today, is mask use indoors and in places like enclosed trains, and enclosed buses and airplanes.
Let's make mask use really easy in those settings. Then in addition to that, masks are really uncomfortable, and they're a constant reminder that we are in a pandemic, they're depressing, demoralizing reminder of where we are as a society. We can't really do anything about that but we can acknowledge it, we can make people feel heard. Then we can start to design better masks that are more comfortable, that are easier to use, and that meet people's style needs. It sounds ridiculous, but this is exactly what we've done to promote condom use. I think it's effective.
Brooke Gladstone: How do you design your way out of the political conundrum?
Julia Marcus: I think it's going to be very difficult to persuade anybody, for example, the baseball player, Aubrey Huff, to wear a mask when it has become a political statement not to wear one. I'm under no illusion that this is a persuadable group. I do want to point to efforts to address the concerns of that group. For example, there was a mask campaign that came out of California just a couple of days ago, a short video put together by a series of California governors, including Gavin Newsom, and Arnold Schwarzenegger.
?Speaker 3: Californians look out for each other.
?Speaker 4: Look, nobody wants to do these things.
?Speaker 5: This is not about being weak.
?Speaker 6: Is about fighting the disease, and keeping our families and ourselves safe.
?Speaker 4: COVID-19 is still spreading.
?Speaker 5: It didn't go away just because you more or less open at 50% capacity.
?Speaker 3: This isn't over.
?Speaker 4: It's up to all of us to fight it.
?Speaker 5: Do your part.
?Speaker 6: Don't let COVID win. Wear a mask.
?Speaker 5: Just do it.
?Speaker 6: Just do it.
Julia Marcus: It, first of all, acknowledges that nobody wants to wear masks. It starts from that place of hearing people's concerns and dislikes about this new public health intervention. It also frames masks as a collective weapon against COVID as opposed to a sign of weakness. You have Arnold Schwarzenegger, The Terminator, saying, "This is not a sign of weakness." Rather than an infringement on civil liberties, it frames masks as a ticket to social and economic freedom. Whether it'll be effective, I don't know but I think it's an example of how to take concerns including political ones, and turn them into public health messaging.
Brooke Gladstone: With respect to the issue of pandemic shaming, what do you think people should do when they see someone else behaving in a way that poses a risk to themselves or others, or should they just mind their own business?
Julia Marcus: It is their business. When somebody on the airplane next to you is not wearing a mask, they're putting you at risk. It's well within our rights to ask the people around us to wear a mask or to keep their distance if we can't just move away from them ourselves. I think in terms of public health strategy when we shame people, we stigmatize their behavior, we drive it behind closed doors, where it becomes higher risk and more difficult to address.
I understand the shaming. Don't get me wrong, I understand the anger at people who are putting others at risk, particularly people who are vulnerable, and especially in this highly politicized environment, it's really hard to avoid that outrage. As a public health strategy, it will not work.
Brooke Gladstone: Thank you very much.
Julia Marcus: Thanks so much for having me.
Brooke Gladstone: Epidemiologist, Julia Marcus, is an assistant professor at Harvard Medical School. Thanks for listening to this podcast extra and join us for the big show sometime around dinner on Friday.
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