I read with interest the recent MedPage Today article “Demanding Thanksgiving Abstinence is Not Public Health.” In it, Vinay Prasad, MD, MPH, argues that as public health officials, we should not be admonishing Americans to avoid Thanksgiving altogether during this COVID-19 resurgence. We should be more compassionate, he says, understanding that people are human beings with needs, and that many are going to do Thanksgiving the way they want to anyway. And knowing this, we should figure out how to listen to what people are telling us and work with them on ways to reduce risk without torpedoing their basic need for holiday connectedness after a long year of isolation.
This is our classic “harm reduction” approach, which is adapted from public health work with people who struggle with substance abuse, and reflects “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use,” or in this case, not adopting behaviors that increase the risk of COVID-19. Harm reduction is also defined as “a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”
I agree with the harm reduction approaches for this ongoing pandemic proposed by Dr. Prasad and others, as shaming people into behavioral submission to prevent spread of the novel coronavirus isn’t the answer. Where I differ is that there is indeed even more nuance to this topic than the article suggests.
First, when we say that telling people to avoid Thanksgiving is an “abstinence-only” approach, we are automatically creating parallels to historical and current public health language and approaches with substance abuse, teen pregnancy, and the HIV epidemic. In these examples, abstinence-only speaks to people simply avoiding behavior that can lead to untoward consequences – such as IV drug use or sex.
While there are parallels here to Thanksgiving, in general principle abstaining from substance abuse or certain sexual behaviors embodies a lifestyle change, not a skipping of a one-time holiday that, to be honest, is a luxury, not a necessity. Moreover, just stopping a behavior may be achievable for some, but not for others, so more realistic options must be offered.
Second, since we are using language from public health approaches with substance abuse and the HIV epidemic, it is useful to refresh our memories as to what actually happened back then. During the early 1980s when HIV first began to emerge, we knew that condoms worked, but to be honest, not everyone liked using them and/or could get access to them. Additionally, we didn’t have any medications or effective treatments for HIV, so people were dying in droves. We didn’t even have the prospect of a vaccine on the horizon to look forward to — and still don’t 40 years later.
While flying by the seat of our pants trying to handle the HIV epidemic that was decimating white gay communities, people who used IV drugs, and in Black and Latin communities, we sometimes encouraged drastic measures like telling people to avoid sex and IV drug use altogether.
The public health messaging was often judgmental and laced with stigma, but one could argue that we were in a crisis situation at the time and needed to do what was needed for the health of our communities while we waited on our government to even acknowledge that HIV existed and that treatments could be developed. Sound familiar?
Back then, I remember people being scared — even without the public health messaging. I recall this because I was petrified as well. We didn’t need a doctor or public health official to tell us how serious HIV was, as we saw it every week in the obituaries or when a friend suddenly didn’t show up for a social gathering. People were here one day and gone the next.
Many were reluctant to have sex back then, even with condoms, while others listened to scientists and that, combined with what they were seeing on the ground, was enough to encourage additional precautions.
We live in different times now. There is a campaign to discredit science, facts, and truth. Healthcare workers who risk their lives daily to treat people with COVID-19 are being smeared in political and media outlets as greedy people just out to make a buck off the pandemic. Many are burned out, have become sick, and/or died from the virus, and some have suffered such tremendous mental health trauma from witnessing death on a daily basis that they have resorted to taking their own lives.
So as a medical community, we should give our colleagues a little wiggle room for knee-jerk reactions to social media clickbait when hearing about people not taking this pandemic as seriously as we know it is.
Truth is, we don’t have comparable harm reduction tools for COVID-19 — like needle exchange programs for IV drug use and pre-exposure prophylaxis for HIV prevention. Until the vaccine arrives, which may be months away, all we have in our toolkit are masks, handwashing, and physical distancing. That’s all we got.
You’ll have to excuse many medical and public health professionals if they resort to endorsing “abstinence-only” COVID-19 prevention approaches as a temporary solution for holiday gatherings. They are not trying to imprison anyone by suggesting they skip Thanksgiving this year — they are merely trying to save lives and salvage what little is left of their physical and mental health in the process.
Finally, public health is indeed a service industry in that its primary purpose is to serve our communities. However, the fundamental flaw in declaring it a service industry like Walmart or Target, is that we are charged with the ethical responsibility of trying to educate and empower people beyond thinking only for themselves and their families when it comes to epidemics and disease states, as well as challenging them to understand how their behaviors may affect others as well.
This is the basic distinction between one-on-one clinical encounters and public health. The former simply focuses on what’s best for the patient, while the latter considers both the patient and our larger communities. It’s a formidable task when living in a country that thrives on and rewards narcissistic behavior like a prize won at a county fair.
There is no “right” way for public health officials to respond to this never-seen-in-our-lives-before pandemic. There is just a continuum of options that may be employed that should be patient-centered and appreciate human behavior and the desire for connectedness that COVID-19 has discarded like proverbial trash.
This is especially true when treatments for the virus are both expensive and limited, and the vaccine may be months away from reaching a general population that so desperately needs it.
While avoiding Thanksgiving altogether may not be the flavor for everyone’s public health palate, given the circumstances and urgency of this situation where many still are not wearing masks or maintaining distance by choice, it may not be too unreasonable as a short-term suggestion.
Our job as public health officials shouldn’t be to avoid “abstinence-only” speak altogether, but rather to figure out how to better communicate this as a temporary strategy so that our families, friends, and communities may consider it without shame, stigma, or feelings of coercion.
It may not be fruitful to lecture communities on how to react to this pandemic, but it is equally unproductive to lecture healthcare workers on how to react as well. We are all going through this together.
David Malebranche, MD, MPH, is a board-certified internal medicine, HIV, and sexual health physician who resides in Atlanta.