Public Health & Bioethics

Science, Faith and AIDS: The Battle Over Harm Reduction
Matthew K. Wynia, Public Health Editor

There are phrases in the political sphere that are carefully crafted so that no one could possibly be against them. They come from all sides of the political spectrum. Perhaps the most well-known are the “pro-choice” and “prolife” monikers adopted by those on either side of the legal abortion divide. After all, who could be against choice, or for death? Only slightly less well-known are the Reagan administration’s renaming of atomic radiation as “sunshine rays,” or the recent Bush administration “healthy forests” and “clear skies” initiatives. Whether such appellations are truthful or not is beside the point; or at least it’s beside my point, which is that such names are designed for political purposes, not strict accuracy. Within public health, one such phrase is “harm reduction.” Since no one could possibly advocate for increasing harms, you might be surprised to hear how very controversial harm-reduction programs are. Then again, if you understand the politics of names, you might suspect that harm-reduction programs are among the most controversial of all public-health initiatives. If they weren’t so controversial, they wouldn’t require such an unobjectionable name. What are harm-reduction programs? Harm-reduction programs are not intended to cure disease, nor to fully eliminate the risk of disease, but to mitigate the effects of inherently risky behaviors. Because they assume that some level of risky behaviors will persist, they aim to limit the harms that might befall those who engage in these activities. A simple and relatively uncontroversial example is a motorcycle helmet law. Or, for that matter, seat belt laws. There would certainly be fewer traffic-related injuries if no one drove motorcycles, or cars, but since some members of the public insist on driving, we encourage the use of protective devices to reduce the risks. Even these simple examples bespeak the controversy that harm-reduction policies can engender among libertarians. In fact, given these examples it might seem that harmreduction programs simply entail the classic dilemma of public-health ethics: balancing individual liberties against optimizing health outcomes for a population. On one side, are those libertarians who want no pesky regulations hindering their freedom of choice. On the other, public-health experts who want to limit harms, even if they have to limit freedoms in the process. But as it turns out, it’s not nearly so simple. Libertarians are not the primary opponents of harmreduction programs today. Instead, harm-reduction programs are running into much more vocal, and effective, opposition among a group that is emphatically not libertarian:
The American Journal of Bioethics, 5(2): 3–4, 2005 Copyright c Taylor & Francis, Inc. ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265160590961699

religious conservatives. This group is less worried about limiting individual freedom of choice, but very worried that harm-reduction efforts provide tacit social approval of risky, and “immoral,” behaviors. What’s more, they understand the politics of language. So at a recent hearing of the House Government Reform Subcommittee, they began an attempt to rename harm reduction as “harm maintenance.”1 (And who could be for that?) The astute reader will have surmised by now that the harm-reduction battles underway are not about whether people who wear seat belts speed more (they don’t). Or whether speeding is immoral (it could be). No, these battles are about drugs and sex. More specifically, they are about using needle exchange programs and condoms to prevent infections with Human Immunodeficiency Virus (HIV), the virus that causes AIDS. There is a move afoot among religious conservatives, who hold the ears of important policy makers, to reduce or eliminate any mention of condoms in the fight against AIDS and to eliminate U.S. funding for any international programs that might possibly be related to needle-exchange programs. Nearly everyone, liberal and conservative, has endorsed the now-famous Ugandan ABC approach to AIDS prevention (Abstinence, Be faithful, use Condoms), but as New York Times columnist Nicolas Kristof recently noted, religious conservatives are working to re-interpret this as ABc, with condoms a distant afterthought if they are mentioned at all.2 As for needle exchange, conservatives have already succeeded in blocking any federal funding for these programs. The problem, for public-health experts, is that blocking these efforts flies in the face of considerable research demonstrating the overall effectiveness of needle exchange programs and condom use in preventing HIV transmission. The Institute of Medicine, the American Medical Association, the American Public Health Association, the World Health Organization and many other reputable scientific and public-health organizations have examined the data, and all have endorsed harm-reduction programs to prevent HIV infection. The science on these strategies seems clear. But the objections facing harm-reduction programs are not simply about science—they are about ethics. To be precise, they are about science and society and how these
1. House Government Reform Subcommittee hearings of February 16, 2005. Transcript available from the author. 2. Kristof, N. D. 2005. When marriage kills. New York Times, March 30: A17.
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The American Journal of Bioethics

interact to form the basis of the ethical practice of public health. Here is one way to understand the argument. It has been said that President Bush is not much interested in reality as it is today, because he has faith in his ability to create new realities.3 There is a good deal of appeal to this notion—that unpleasant realities can be altered and a new reality created, if only one has faith and the willpower to stick it out and make it so. And indeed, as long as we are discussing socio-political realities, there is a good deal of truth to this line of thinking. Political realities can change based solely on popular will. If the popular will changes, the fundamental facts of the social situation change, and what was once inconceivable suddenly makes perfect sense. In science, however, reality is not so amendable to recreation on the basis of ideology, willpower, and faith. Scientific reality, if you will, can be reinterpreted in light of new facts or new beliefs, but it cannot be changed by dint of will or strength of faith. So which of these forms the basis of public-health programs? Are public-health programs scientific and based on human physiology, or are they political activities based on social factors? Insofar as they are the latter—fundamentally political—faith-based arguments against harm-reduction strategies might hold some truth. Those who object to harm-reduction programs do so primarily because these programs assume that risky behaviors will, at some level, always be with us. But with faith and will, they argue that risky behaviors can stop—if only we don’t do anything that might encourage them. It is a hopeful view of the world. But insofar as public-health initiatives are based on science and human physiology, harm-reduction programs make sense. That is, to the extent some risky human behaviors are biologically driven or otherwise immutable, no

amount of moralizing, religion, or faith can eliminate them. If this is the case, then the best we can do is to reduce harms. This is a realpolitik view of the world—and it is hard to sell at a prayer meeting. We have yet to answer the question, though: Are publichealth programs science-based or are they based on malleable social behaviors? The answer, and the reason the battle over harm-reduction programs will never be completely resolved, is that most public-health measures are, inextricably, both. In other words, public health is the political weaving together of medical science and social factors to create “conditions in which people can be healthy.”4 With regard to AIDS, one might argue over how likely it is that human behaviors around sexuality are likely to change, or how long such change might require and how many people might die in the meantime. And certainly one can argue (based on several good studies) that needleexchange programs do not increase drug use and might even decrease it by bringing addicts into contact with the possibility of treatment.5 But these counter-arguments will not persuade some of those in our society with strong religious faith—because likelihood ratios and other data are essentially irrelevant if one’s goal is to create a new reality. Indeed, the mystery of faith is that it exists not because of demonstrable facts but sometimes in spite of demonstrable facts. Sometimes, faith must be strongest where evidence seems weakest.6 I admire people of strong faith, but I treat people with AIDS. Today’s greatest tragedy of public-health ethics is that because of well-meaning people of faith in the U.S., more people around the world will become infected and die of AIDS. Disclaimer: The views and opinions in the article are those of the author and should in no way be construed as policies of the American Medical Association.

3. “We’re an empire now, and when we act, we create our own reality. And while you’re studying that reality—judiciously, as you will—we’ll act again, creating other new realities, which you can study too. . . ” Unnamed senior administration official quoted in R. Suskind, Without a doubt. New York Times Magazine. Sunday, October 17, 2004. This reflects similar sentiments expressed by others close to the administration. See, for example, D.V. Johnson, Creating Reality, at 12/17.html (accessed April 6, 2005).

4. Institute of Medicine, Committee for the Study of the Future of Public Health. The Future of Public Health. Washington DC: National Academy Press, 1988. 5. Marsch, L. A. 1998. The efficacy of methadone maintenance interventions in reducing illicit opiate use, HIV risk behavior and criminality: A meta-analysis. Addiction 93(4): 515–532. 6. This is not to suggest there is no evidence for religious faith or a belief in God; that would be a subject for a different essay— one not directly related to public health programs. But whether evidence supports God’s existence is a separate issue from whether faith is being used as a rationale to reject harm reduction strategies in public health. I also do not wish to suggest that every person of faith rejects harm reduction strategies; many accept the results of scientific studies around issues of public health.

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March/April 2005, Volume 5, Number 2