Reducing harm: The challenge of difficult choices

PD Gluckman

The concept of harm reduction has a long history as an essential component of public health [1]. It is essentially a matter of making choices and taking actions which on the one hand reduce known health risks,  but on the other may  have other consequences that need to be considered. Immunisation, folic acid supplementation of bread and decisions on the scope of breast, prostate or colon cancer screening are all examples where such harm reduction trade-offs are at the heart of decision making. But each of these cases involves direct health benefits and considerations of known risks of side effects, impacts of unnecessary investigations and cost. Nevertheless, the decisions are still complex and ethically fraught.

Currently we see such principles in balancing risk, cost and benefit in the many decisions being made in different jurisdictions about COVID-19. Different authorities in different contexts around the world are having to make very difficult decisions involving uncertain science (given that it is a virus that we have not encountered before, on which knowledge is still emerging and which is behaving differently to other coronaviruses), with decisions that may have life or death implications for some, and extraordinary personal, economic and business implications for many.

The decisions around ‘flattening the curve’, complete elimination, or accepting almost complete elimination by managing a caseload well below the damage threshold through aggressive quarantine, contact tracing and testing are not easy. In New Zealand, having chosen one of the latter two strategies, we are now struggling with the complexities of border closure, public anxiety, and social and economic distress. And this is against the background of a disease with unexplained characteristics, such as its variable morbidity and mortality, as well as uncertainties over the immune response and the timeline to efficacious vaccine deployment. The tensions between economic needs and precautionary health are palpable and have had led to very different decisions in different countries [2].

However this essay was not initially conceived to focus on COVID-19 and its immediate consequences, but rather because the concepts of harm reduction are increasingly applied in areas where there is even more debate – debate that is related to a broader range of values-based considerations, rather than those of health and equity. Often these are situations where the costs and benefits are difficult to quantify  because they are social and broad, rather than specific and immediate. Further, human, social, and economic capital are not simply exchangeable currencies.  We must engage more broadly in seeking consensus across society. Often such issues to do not necessarily align with traditionally partisan politics [3]; the values considerations often are not easy to reconcile even for an individual within their own personal evaluation – they can be confronted with very conscious cognitive dissonances.

The use of needle exchange for drug addicts is an example of harm reduction strategies where the clear benefit is a lesser risk of transmission of HIV-AIDS and hepatitis within the user group. But if a society approves needle exchange it can be perceived as a tacit societal acceptance that an illegal and dangerous activity will be accommodated. This invites political contestation. Drug testing at rock music concerts – a subject of local debate – is analogous. The issue in both of these cases is whether such tacit acceptance might encourage others to experiment.

Decisions a society makes about vaping also raises such issues. Here the claim for allowing vaping is that it assists smokers to stop, or at least reduce, their exposure to carcinogens and other toxins in cigarette smoke. The evidence of its impact on smoking cessation suggests that while it is effective for some smokers, its greater effect is to significantly reduce smokers’ continuing exposure to carcinogens and toxins [4], with the presumption that this will have long-term health benefits compared to smoking tobacco cigarettes. Either way these are laudable goals and benefit the individual established smoker. But the risk from the outset was that vaping might be seen as harmless and socially acceptable and might encourage young people to take up smoking behaviours, thus becoming a gateway to them taking up cigarette smoking as their nicotine dependence grew. Early claims suggested that this was a high risk – more recent data question this claim beyond the inevitable experimentation that young people always make [5, 6].

Certainly, vaping has become popular with young people in some countries and the vaping industry has played into that market aggressively with the introduction of flavoured vapes, perhaps learning from the successes of alcopops in opening new youth markets for alcohol. On top of that, sadly vaping devices have been used largely in the USA in ways that led to vaping related lung diseases and deaths. This likely primarily relates to specific components of substances put into the devices. Nevertheless the devices themselves do produce aerosolized substances our lungs are not normally exposed to, and health guidelines [7] point out the lack of available information about longer term damage. If the primary argument for allowing vaping is about reducing smoking-related disease, then perhaps the use of vaping should have been restricted to those who are bone fide smokers and, like some other smoker-reduction tools, be seen as a pharmacist distributed product for those certified as smokers. Indeed this was one option I suggested to a previous government. But the pressures of popular use and presumably industry interests have led to much more permissive arrangements.

Later this year, in parallel with the general election, we will face a referendum regarding legalising the social use of marijuana.  Here we are dealing with a quite different debate from that which emerged over medical use where there are now accepted benefits for some particular rare neurological diseases and apparent neuropsychological benefits in end-of-life care.

In the context of the coming referendum, several arguments have been put forward by those in favour of liberalisation. Essentially, they boil down to: other countries are doing it and in those places there is little evidence of any real downsides; legal manufacture and sale will reduce the risks of super-potent or contaminated product reaching the user; and most cogently, its criminalisation blights the lives of those involved particularly in cultivation, distribution, sale and possession. There is also an enthusiasm amongst some for the potential industrialisation of its legal manufacture, supply and taxation. The arguments against liberalisation have largely been either about claimed side effects – the robust evidence for the development of psychotic and apathy syndromes in heavy users who start at a young age [8]; or about safety related to impacts on driving and machinery use, for which the evidence is less robust.

Beyond these cogent but antagonistic arguments, advocates on either side of the debate use broader arguments related to their own values and worldviews. Concepts of libertarianism, individual responsibility and orthodox views related to law and order have all surfaced. Here we have a case of a debate over harm reduction where advocacy and claims of fact on either side are being made with somewhat limited evidence, that is subject to contested interpretation. This is not surprising given that fundamentally different values are in contestation and these may in fact be held at the same time by the same individual.

But beyond the immediate debate leading up to the referendum, there are three questions that need to be asked and yet are not surfacing.

Firstly, why does a 21st century advanced society need mood-changing drugs? Is this the way to achieve some utopian nirvana, or have we altered our society so much that our emotional well-being is not possible without the aid of psychoactives? Is this saying something more about how we now live our lives, or at least the expectations we put on our lives?

Secondly, given the robust evidence that young brains are particularly at risk, what are we doing about reducing the likelihood of use in young people? In contrast to some other countries, we have failed dismally in Aotearoa-New Zealand with respect to the responsible use of alcohol by young people. Here, Iceland is a stellar example [9], albeit in a very different context which took a co-design process together with young people to progressively change the culture over two decades. Interestingly the the reduction in alcohol use by young Icelanders appears to also have been associated with a reduction in drug use. Sadly there is growing evidence of a rapidly rising rate of mental morbidity in teenagers in many countries including New Zealand [10, 11], and more psychoactive exposure in this at-risk population cannot do good even though it is an understandable response to stress.The question remains of how to promote emotional self-regulation in a fast changing society such as ours.

Thirdly, the challenge of blighted lives of those involved in illegal drug production, supply and use is real. It is closely linked to discussions about how to handle other drugs of abuse, some of which are clearly much more harmful and addictive such as methamphetamine. Should we take a primarily health-based approach as some other countries do, or continue with a punitive approach?  And in turn there are the broader issues of gangs and communities where intergenerational disadvantage and deprivation persist despite many claimed magic bullets having been applied across the political spectrum.

Legalising marijuana in itself will likely have little impact on these broader – and I suggest fundamental – issues. Finding solutions to these deeper realities will be hard and sadly will continue to be politicised. Politicians love to be seen as being tough on crime, and repeated policy moves by administrations across our political landscape have filled our prisons with young Māori men [12]. Change requires a life course approach and broad multidimensional investment in response to evidence that is overwhelming . This includes open consideration of issues which many may find uncomfortable to even consider, such as post-colonialism, ethnic bias, and growing inequalities.

How New Zealand might address these questions will likely not affect how voters will vote in the September referendum, but this should not be an excuse to avoid asking them. It would be healthier for our societies if the deeper issues associated with harm reduction were higher on our collective agenda; they require deeper thinking and difficult but hopefully civil conversations.

Perhaps as we reflect on the many decisions that government must make on our behalf in relation to the COVID-19 crisis, and the obvious challenges it will pose to our societal resilience and priorities and to our personal and social lives, we can reflect on the lessons that might give us our long-term health as a society.

» See Commentary on this blog post by Prof Richie Poulton

References

[1] Marlatt G A (1996) Harm reduction: Come as you are. Addictive Behaviors 21(6): 779-788.
[2] The INGSA COVID-19 Policy making tracker documents policy decisions undertaken by various jurisdictions and enables comparative visualization.
[3] Lakoff G (2008) The Political Mind: Why You Can’t Understand 21st-Century American Politics with an 18th-Century Brain. New York, NY: Viking.
[4] Hartmann‐Boyce  J, McRobbie  H, Bullen  C, Begh  R, Stead  LF, Hajek  P (2016) Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD010216.
[5] Warner KE, Mendez D (2019) E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the Potential Benefits of Increasing Smoking Cessation. Nicotine & Tobacco Research 21(1): 41–47.
[6] See ‘Key Messages’ in: Ministry of Health. Vaping and smokeless tobacco, accessed 23 June 2020.
[7] Ministry of Health (2016). Electronic Cigarettes: Information for health care workers. HP6502.
[8] Boden JM, Dhakal B, Foulds JA, Horwood LJ (2020) Life‐course trajectories of cannabis use: a latent class analysis of a New Zealand birth cohort. Addiction 115: 279-290.
[9] Arnarsson A, Kristofersson GK, Bjarnason T (2018) Adolescent alcohol and cannabis use in Iceland 1995–2015. Drug and Alcohol Review 37(Suppl 1): S49-S57.
[10] Bowden N, Gibb S, Thabrew H, Audas R, Camp J, Taylor B, Hetrick S (2019) IDI trends in antidepressant dispensing to New Zealand children and young people between 2007/08 and 2015/16. New Zealand Medical Journal 132(1505): 48-61.
[11] Gluckman P (2017) Youth suicide in New Zealand: a Discussion Paper. Auckland: Office of the Prime Minister’s Chief Science Advisor.
[12] Office of the Prime Minister’s Chief Science Advisor (2018) Using evidence to build a better justice system: The challenge of rising prison costs. Auckland: Office of the Prime Minister’s Chief Science Advisor.