Medical Examiner

How Harm Reduction Can Help Us Live With COVID

A sign in an airport terminal says facial coverings must be worn.
A sign stating that masks are required at San Francisco International Airport stands in a terminal after the federal mask mandate for airports and pubic transportation was lifted, on April 19. Justin Sullivan/Getty Images

Last week, White House COVID briefings started up again after being on hiatus since April. They’ve got a new look now, with the president’s pandemic response coordinator presenting in front of a giant screen. Cases are on the rise, Ashish Jha said, and Congress isn’t ponying up much funding. The director of the CDC weighed in, saying that nearly a third of the United States is at a “medium high” community transmission rate, encompassing places like New York City. That’s the point where the government says to consider precautions like masking indoors. So I called Dr. Deepika Slawek, an assistant professor at the Division of General Internal Medicine and an attending physician at Montefiore Comprehensive Family Care Center in the Bronx. I wanted to know how her job was changing as she stared down another wave—but she said a lot of it is staying the same. Nearly a thousand people are hospitalized in the city right now, and case counts have jumped up 18 percent, but Slawek is taking a new approach to how we handle COVID today: through harm reduction. On Wednesday’s episode of What Next, I spoke with Slawek about having seen the worst of the virus and adjusting to current conditions. Our conversation has been edited and condensed for clarity.

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Mary Harris: You work with immunocompromised patients, right?

Deepika Slawek: Yeah, a good number of my patients have HIV. Other of my patients might be immunocompromised because they have cancer, or other conditions.

When your patients see this high COVID alert, what do they think? Does it feel different for them?

Some of my patients, they are. I talk to them and they’re like, “Don’t worry about me. I stay inside my house all the time.” While, like, I’m just used to it by now.

It’s hard to know how to feel about that.

I know. And they’ve developed this form of resilience where they’re just like, “No, I’m cool with just staying at home. I’ve created my systems.”

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Last week, around the same time that the White House was ringing the alarm about rising COVID levels around the country, the mayor of New York was figuring out how he was going to respond to the fact that his city had moved to a high risk level. There was a little bit of a disconnect during his press conference: He wore a mask, but when he was asked if he was going to require masks indoors—because his own guidance says that’s what he should be doing—he said no. I wonder what you made of that decision.

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What the past two years has taught me is that these decisions are both public health decisions and political decisions. From a medical standpoint, I’m telling my patients to wear masks indoors. I think that a mandate is another strategy to doing that. We’ve seen in some situations where it works. In other situations, there might be a mandate and people don’t follow it. You can make a mandate and direct people to do a thing, but that doesn’t necessarily mean that it translates to exactly those actions.

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Well, it’s how you are enforcing it.

Right. I have that experience clinically, constantly, where I tell my patients, you must do X, Y, and Z, take your medication every day and wash your hands constantly or whatever. This person has their own agency as an individual, so I have to arm them with the knowledge that they need to make that decision.

There are different ways to go about this, and I think what I’ve learned to become very comfortable with is that we have to understand we don’t know the future, but we know what the possibilities are. We know the possibility is that with this increase in cases, we’re going to have more hospitalizations and we have to be ready for it.

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It doesn’t mean that we don’t do things to try to stem it. I have lots of patients who will send me messages saying, “I’m going to go do this thing. Do you think that’s OK?” I’ll tell them yes or no based off the risk level—at least we have that tool in our bag. I can tell my patients to test frequently and let me know if they get sick so I can get them antivirals, all of that. But if there’s going to be a huge increase in cases, I just have to be ready for that as a possibility. I can’t just wish it away.

If you could advocate for the mayor to do one or two things right now to address the spread of COVID, do you know what you’d tell him?

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Perhaps he could try doing something like a lot of what my colleagues and I do. What we do is try to tell people of a range of things that they can do to reduce their risk. I consider that a harm reduction policy: Here are things you can do to reduce your risk of getting COVID. One of them, the safest thing you could possibly do, is wear an N95 all the time, be vaccinated, have your booster if you can, and test frequently. On top of that, make sure we have adequate resources to treat people if and when they get sick: get people’s packs delivered or offer monoclonal antibodies. People need to be aware that they can and should get those things.

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If people are familiar with the idea of harm reduction, they’re probably familiar with it in the frame of addiction. I’m curious if you can lay out how the harm reduction frame works for addiction and how you’d translate that to COVID, because people might not see those things as related.

I’m a little biased because I’m an HIV and addiction medicine doctor, so I’m working within the harm reduction framework basically all the time. I sometimes like to apply it to my own life. The way I think about it is that it’s virtually impossible for any of us to be perfect in our actions. I think it’s virtually impossible even for a trained infectious disease physician to do everything perfectly all the time to avoid getting COVID or getting sick. But what you can do is instill smaller measures in order to reduce that risk.

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There’s no doing it perfectly. If we could do a few things to try to reduce risk when we know for sure that there are people who are not going to be able to follow the guidance 100 percent, then we should do those, even if it ends up being one thing. You don’t wait until it’s perfect to implement something. If you know that something is going to be helpful, you do it.

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This idea that we accept bad things will happen, that we’re going to try to build bumpers around the bad things so that things are less likely to go disastrously wrong—do you feel like that’s been hard to implement?

It’s been so, so hard. Our country was founded on principles of doing everything we can to be as perfect as possible. We almost have to unlearn that before we can learn the idea of being OK with things not being perfect.

We know this from other from other health conditions, right? We know this from HIV: You don’t get anywhere with HIV prevention unless you have tools like safe sex messaging and PrEP and injection drug use that is safe. You can’t get to prevention without talking about those things.

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