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May 12 2008

The Harm Reduction Model of Life

Harm_reductionDue to both chance and temperament, I have a lot of friends who work (or have worked) in public health. (Including, of course, my darling wife.) As a result, I hear a lot about the concept of harm reduction. And once I started learning about harm reduction, I found that it isn’t just a useful model for public health and public policy. It’s an unbelievably useful model for life in general.

It’s a concept that I think a lot of people would be interested in. Humanists especially, but not just them. So I thought I’d take a moment and gas on about it for a bit.

Let’s talk about public health for a moment first. For those who aren’t familiar, here’s the basic idea. When dealing with a public health problem, the harm reduction model says that you don’t necessarily have to completely solve or eliminate the problem in order to make important improvements. It’s a worthwhile goal to simply reduce the degree of the problem, reduce the harm done by the problem, and improve the quality of life for people experiencing the problem.

Teenage_dope_slavesIn fact, harm reduction proponents often don’t see “problems” the way society as a whole typically does. Rather than making moral judgments about drugs or sex or whatever, the harm reduction model accepts these things as basic human behaviors that have been part of life for as long as we’ve been around. It doesn’t see these things as problems per se, but as elements of human life that can sometimes cause problems. And rather than passing judgement on where people need to be in their lives before they can use or deserve help, it aims to “meet people where they are” — whether that’s regarding drug use, sex, or whatever — and to give everyone who wants them the tools they need to reduce harm in their lives.

(It’s essentially the opposite of a “zero tolerance” or “abstinence-based” model. If you’re curious, the Harm Reduction Coalition has a more detailed explanation — as it relates to drug use, which is where the concept originated, but the principles can be applied to many other public health and public policy issues.)

In other words, you don’t have to make problems disappear. You just have to make them better. (And in some cases, trying to make problems disappear can actually do more harm than good.)

Needle_exchange_suppliesThe classic example of harm reduction is needle exchange. Needle exchange programs are a response to the high rate of HIV transmission among injection drug users: they give clean needles to users in exchange for used ones, so users aren’t sharing dirty needles. Now, a “zero tolerance” policy would say that illegal drugs are, well, illegal, and bad, harmful to the users and to society, and society can’t condone their use in any way — including giving clean needles to users.

Harm reduction, on the other hand, says that:

a) it’s good to reduce HIV transmission in injection drug users, since that will reduce HIV transmission in the general population;

b) it’s good to reduce HIV transmission in injection drug users, so that more of them can have healthy lives when and if they do get sober (“you can’t get clean if you’re dead” is a classic needle-exchange saying);

c) it’s good to reduce HIV transmission in injection drug users, because they’re, you know, human beings. Their lives have value. The fact that they’re injection drug users doesn’t change that. It is worth helping them stay alive and stay as healthy and happy as possible… as much as it is for anybody.

Its_perfectly_normalAnother example is sex education. Zero tolerance says that underaged sex is an unequivocal evil that cannot be tolerated by society, and the only appropriate response is to try to stop it entirely. The harm reduction model says that, even if you don’t love the fact that minors are having sex, you not loving it is not going to stop it from happening… and we therefore need to find the most effective ways to stop its harmful effects, such as teenage pregnancy and STIs. (Abstinence- only sex education is a zero- tolerance approach… and it’s a classic example of zero-tolerance not only being ineffective but actually doing harm.)

Take a wild guess which model I support.

Okay. Enough with the public health. What do I mean by the harm reduction model of life in general?

What I mean is this: Even if you can’t completely solve a problem or make it go away, it is still worthwhile to work on making it better. Sometimes better is enough.

VoteVoting, I think, is a good example. And the coming Presidential election is an excellent one. We don’t have to elect a perfect candidate, or even one we’re wildly enthusiastic about. We just have to elect a President who’s a whole lot better than the current one. It won’t make things perfect… but it’ll make things better.

Ten_minute_activistAnd the harm reduction model can be applied to all sorts of political and social problems. Can you personally solve the global warming crisis? No — but you can help reduce its effects (driving less, buying energy-efficient appliances, voting for candidates who support strong environmental policies, etc.). Can you personally stop the waste and poor health caused by industrialized food production? No — but you can buy more of your food from local sources, and push for the same in your schools and restaurants. Can you personally eradicate racism, sexism, homophobia? No — but you can try to be conscious of it in your own life, and speak out against it when you see it, and pay attention to it when you vote. Can you personally halt the spread of obscene American consumerism? No — but you can cut back on the amount of pointless crap you buy. Etc., etc., etc.

And if enough people take enough of these steps, it’ll make these problems better. It won’t eliminate them, but it’ll reduce their harmful effects. And it may even help change the culture that cultivates them. Especially if you apply the harm reduction model, not just in your personal life, but in political and cultural action.

But the harm reduction model doesn’t just apply to politics and social change. It can be applied to almost any area of life.

StrawberriesDiet, for instance. I have long ago given up on trying to have a perfect diet, or to lose a significant amount of weight. Instead, I’m focusing on having a better diet, a good enough diet, a diet that most of the time consists of fruits, vegetables, whole grains, and low-fat proteins with minimal animal products. I’m trying to have a diet that keeps me reasonably healthy and still lets me relax and enjoy life. And instead of trying to lose weight, I am instead trying to not gain weight… and to stay as healthy as I can at the weight that I am.

Ditto exercise. I don’t need to get the ideal recommended amount of exercise in order to feel obvious improvements in my life and health. I just need to get more exercise than I’d been getting before I started working out.

Or take housecleaning. Savings and money management. Not reading enough. Watching too much TV. If there’s an area of your life that you’re not happy with, you don’t necessarily need to completely re-structure your life so that you can perform the task in question to your complete satisfaction. You just need to moderately re-structure it, so you can do more of what you like and think is important, and less of what you don’t.

So that’s the idea.

And here’s the thing I really like about the harm reduction model of life, the thing that transforms it from a helpful hint into a defining philosophy:

It lets you be both an optimist and a realist.

Half_full_glass_of_waterI hate the idea that optimism is somehow a form of delusion, and that pessimism and cynicism are somehow equivalent to realism. And I don’t just hate it because I enjoy being an optimist. I hate it because I think it’s bullshit. I think pessimism and cynicism are often just a weak-ass rationalization for being lazy or cowardly, irresponsible or selfish. Realism doesn’t just mean being aware of problems and limitations and obstacles. It also means being aware of what can and cannot be done about problems and limitations and obstacles.

Happy_face_ballAnd that’s where the harm reduction model of life comes in. It gives us room to be positive about life and hopeful about the future, without being deluded or willfully ignorant about limitations and harsh realities. It transforms the Sisyphian experiences of life, the rocks that get constantly pushed up the hill only to roll back down again: it keeps them from feeling frustrating and pointless, and instead lets us see them as positive accomplishments. It doesn’t let us off the hook about doing what we can for ourselves and for others — IMO, it does the exact opposite — but it lets us feel okay about not doing it perfectly.

Realism doesn’t give us an excuse for irresponsibility and inaction. It gives us the moral obligation to be responsible, and to take whatever action is possible. And the harm reduction model gives us a model for doing exactly that. It gives us a framework for dealing with problems that seem appalling, enormous, and fundamentally unsolvable… without succumbing to apathy, cynicism, or despair.

CadillacescaladeesvNow, the big downside of the harm reduction model of life is that it can easily become an excuse for doing a half-assed job. It can act as a justification for doing the least you can do; for taking only those actions that don’t inconvenience you; for making token gestures towards personal improvement or social responsibility while still being fundamentally lazy and selfish. “Hey, I changed all my lightbulbs to fluorescents — I don’t have to get rid of my SUV!”

And believe me, I speak from personal experience here. I’ve spent fifteen minutes picking up the tornado of books scattered all over our living room and piling them into neat little piles, as a “half-assed harm- reduction” form of housecleaning. I’ve given twenty bucks to political causes or candidates as a “half-assed harm- reduction” form of political action, when I was too busy or lazy to write letters and make phone calls and go to demonstrations. And more seriously, I’ve used the fact that I recycle and use fluorescent lightbulbs as a “half-assed harm- reduction” rationalization for the fact that I don’t really do that much about global warming, even though I think it’s by far the single most pressing problem facing our generation.

CompactflourescentbulbBut as my friend Laura Upstairs (one of my many friends in public health and public policy) pointed out, one of the whole points of the harm reduction model is that a half-assed job is often better than none. Piling the books into neat squares isn’t a very good form of housekeeping… but it’s better than leaving them lying around everywhere. Donating twenty bucks to candidates or causes isn’t the most powerful form of political activism in the world… but it’s better than taking no action at all. Using fluorescent lightbulbs isn’t really a sufficient response to global warming… but it’s a better response than not using them.

And in my experience at least, a half-assed job is often a step towards a more completely-assed job. It can get you started with good habits — habits of thinking, as well as habits of action — that can eventually get you doing more than you’d ever imagined.

Biceps_curlHere’s what I mean. Going to the gym once a week may not improve your health that much… but it can get you into the habit of paying attention to exercise and health, and can be a step on the way to eating better, and being more active in your everyday life, and eventually going to the gym two or three times a week. Recycling may not make a huge dent in our planet’s diminishing resources… but it can get you into the habit of thinking about waste and conservation and what the planet can and can’t sustain, and thus inspire you to drive less, and not buy as much disposable crap, and vote for funding for solar power and public transportation. Etc., etc., etc. Yes, a harm reduction approach to life can get you feeling complacent and smug when you’re not actually doing very much… but it can also nudge you in the direction of doing more.

Dr_nick_rivieraThe harm reduction model isn’t always appropriate. There are, for instance, times when perfectionism is exactly what you want. I don’t want a brain surgeon who thinks, “Oh, we got most of the tumor, I’m sure that’s good enough.” I don’t want an air traffic controller who thinks, “Well, one crash a week is better than five crashes a week.” And when it comes to major public issues like global warming, it is well worth asking whether moderate harm-reduction steps are actually going to make a significant dent: whether they actually will reduce harm enough to keep disaster at bay, or are really just a way of making ourselves feel useful while we collectively walk off a cliff.

So the harm reduction model of life isn’t a cure-all. But I’ve found it to be a singularly useful philosophy. It’s given me a way to reconcile my native optimism with my native hard-assed realism, without sending me into a cognitive- dissonance headspin. It lets me be optimistic without being deluded; it lets me be realistic without being a buzz-kill. And it’s given me a way to not feel overwhelmed by enormous, seemingly impossible tasks, both personal and political. It lets me do the small amount that I can do in this world, without feeling like it’s pointless.

And that rocks.

(Thanks to Ingrid and to Laura Upstairs, for their help with the explanation of the public health stuff. If I made any mistakes, it’s my fault, not theirs.)

19 comments

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  1. 1
    efrique

    I don’t want a brain surgeon who thinks, “Oh, we got most of the tumor, I’m sure that’s good enough.”
    If the alternative is to do nothing, actually, maybe I do want on like that (unless there’s evidence doing nothing is actually better than getting almost all of it).
    I don’t want an air traffic controller who thinks, “Well, one crash a week is better than five crashes a week.”
    I sure as hell want one that thinks one crash is better than five! After that first one, I DO NOT want one that says “ah well, this week is all shot to hell, just let ‘em crash and we’ll try harder next week. This was a bad week to give up sniffing glue.” I want one that thinks four more crashes is at about five times as bad as the one crash that just happened.
    And when it comes to major public issues like global warming, it is well worth asking whether moderate harm-reduction steps are actually going to make a significant dent: whether they actually will reduce harm enough to keep disaster at bay, or are really just a way of making ourselves feel useful while we collectively walk off a cliff.
    Well, if the harm reduction is actually reducing harm in a reasonably cost effective way, then it’s probably better than doing nothing. If you’re saying “it’s really doing nothing” then it’s not really harm reduction. As long as we’re doing whatever we’re doing with open eyes and not letting it get in the way of looking really hard for ways of doing even better, I say go for it.
    Yes, it’s no panacaea. Nothing ever is.
    So let’s just:
    - do whatever we can to make things better
    - keep checking to make sure we actually are*
    - keep looking for better approaches than we have
    * so, when abstinence-only sex-ed turns out to be worse than useless, we don’t allow people to get away with continuing to argue that we just have to pray harder ‘cos if we did it right jeesus would stop all teh evil sex.

  2. 2
    efrique

    Damn it. All my lovely italicized quotes and unitalicized responses are all just plain text. Yuk.

  3. 3
    jeff huckaby

    I think you are a great human being…I love you!

  4. 4
    Jocelyn

    Thanks so much! I really appreciated reading this. I tend to be a terrible pessimist, and don’t want to be, so it’s really nice to have positive reinforcement for how I would like to think. And act. Cheers!
    -Joss

  5. 5
    Bill Brent

    Hi, Greta — optimism, realism; yes, I’ll take both kinds of cake, please!
    I’m posting a link to a related article on my blog in case it’s useful to anyone reading this:
    http://litboy.typepad.com/my_weblog/2007/06/uncomplicate-my.html
    –Bill
    http://www.LitBoy.com

  6. 6
    Sarah

    I’ve been reading your blog for some time now, and this post moved me into commenting. I was hoping to quote for you this brilliant quote about how a great writer articulates what the reader has already been thinking or feeling, but I couldn’t find it, except out of my convoluted memory. That quote IS your writing. You’ve manage to say what has been tangled up in my head so many times. So thank you, and keep on being brilliant.

  7. 7
    dryad

    Harm reduction strikes me as a really useful model for people with chronic depression. I have a loved one who tends to become mired in guilt when he can’t do everything he thinks he should, and the result is that he often can’t do much of anything. But harm reduction sounds like a good way to break out of that kind of all or nothing thinking.

  8. 8
    C. L. Hanson

    This is only tangentially related, but I love that book “It’s Perfectly Normal.” That was the item I purchased on my pilgrimage to Good Vibrations in San Francisco, for my (at the time, future) kids. :D

  9. 9
    Kay

    Wow… I always love reading your stuff but this time I just wanted to say Thanks!
    I hadn’t heard about the Harm Reduction method… and I can really see how it is both practical and easy to incorporate into one’s life… It sort of goes along with one of my favorite modes of thought “some is better than none”.
    Some exercise is better than none, Some writing is better than none, some housecleaning is better than none, some time with my lover is better than none… etc.
    Keep up the awesome writing GC, you have a loyal and very happy fan here in CA.

  10. 10
    CHADMAC

    Long time reader, second or third time commenter…..
    I’ve always approached most aspects of my life from this perspective. I just didn’t realize it had an actual name…… The More You Know.

  11. 11
    markbt73

    It’s always strange to hear that a philosophy you’ve always sort of thought would be cool has a name, and it’s always nice to hear that other people think and feel and act the same way.
    Very few things upset me more than zero-tolerance mindsets, or defeatist attitudes that say “oh well, it’s too late anyway.” Whenever I hear either of those arguments from now on, I’m going to point people to this post.
    Thanks for writing this.

  12. 12
    feh

    What a great post, and blog in general. The work I do falls under the harm reduction philosophy, in fact it is completely directed by it. There is one important thing you omitted that I think people should know about harm reduction, and that is “Every positive change is celebrated”. That means every little change you make to improve should be celebrated. Even if it’s just saying to yourself, “hey, good job on recycling this week”, or “yay! the floors are swept”, or even “Good on me for using a condom when I blew that guy”, celebration, or at least acknowledgement, is a big part of the harm reduction approach.

  13. 13
    cl

    Greta, this is real talk:
    “I hate the idea that optimism is somehow a form of delusion, and that pessimism and cynicism are somehow equivalent to realism. And I don’t just hate it because I enjoy being an optimist. I hate it because I think it’s bullshit. I think pessimism and cynicism are often just a weak-ass rationalization for being lazy or cowardly, irresponsible or selfish. Realism doesn’t just mean being aware of problems and limitations and obstacles. It also means being aware of what can and cannot be done about problems and limitations and obstacles.”
    I’ve been trying to get so many of my unmotivated friends to understand this.
    I really thought you were going to apply the Harm-Reduction ideas to religion and science. In fact I can’t believe you didn’t. You know, for example, some creationists want to know EVERY aspect of God, some evolutionists want to know EVERY aspect of evolution, when in reality, neither is attainable, nor is the full knowledge of such subjects necessary for a fruitful life in day to day affairs…

  14. 14
    Alexis Kauffmann

    Dear, this blog is a vaccine against mental numbness!

  15. 15
    Donna Gore

    Greta,
    Just came across this and thought you might be interested. It’s applying the harm reduction model to addiction.
    http://ezinearticles.com/?What-We-Can-Learn-From-The-Audrey-Kishline-Tragedy—The-Case-For-Harm-Reduction&id=1160854

  16. 16
    PorkChopTze

    Hi Greta
    I very much liked this blog entry on harm reduction–I stumbled across it because I am the author of the Kishline piece mentioned above. My whole liefe revolves around harm reduction–I hope it is okay to post the URL to my harm reduction site
    http://hamsnetwork.org

  17. 17
    Jacobus

    Thank you! Good thoughts. I spent two decades with someone who had zero tolerance for anything that didn’t perfectly fit her views of “right” and I’m still recovering. My current GF is not perfect, thankfully, and neither am I… and it’s okay. It really is okay.
    Hugs to ya.

  18. 18
    Jimmy Crummins

    Outstanding article. A lot of good points here. Thought it was well thought out and articulated.

  19. 19
    Sensemaker

    Harm reduction is indeed a very good model in many, perhaps most situations. The fact that something cannot be perfect is a very poor excuse for doing nothing concrete to improve it. However, there are some situations where, in my opinion, you simply have to refuse to cooperate with an atrocity, even if doing so might reduce harm. This is not an easy question.
    If I am a medical officer responsible for the health of a bunch of mercenaries who are going to rape the civilians of a city they have just conquered should I give them contraceptives (so they don’t bring VD to their victims) and restraining devices (so they do not need to use so much violence)? Or should I simply refuse to have anything to do with this atrocity thus increasing the suffering of the victims?
    This is a real issue. Some of the people who helped make the Holocaust happen defended themselves by saying that they treated the Jews slightly (very slightly) more humanitarian than the others. If they didn’t do it someone else would do the same job in a slightly more brutal way. Using the “harm reduction” model they claimed their actions were defensible.
    When slavery was still an issue there was a very real divide between the “pure” abolitionists and those who wanted to make life better for the slaves. The “pure” abolitionsists argued that by humanizing slavery they implied moral sanction and perpetuated it.
    What you are saying is correct except perhaps: “It can be applied to almost any area of life.” I say there are many cases where you must refuse to cooperate with an atrocity even if doing so would indeed reduce harm. On issues such as rape or slavery, I believe zero-tolerance is necessary.
    Sensemaker

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