Harm Reduction for Reciprocal Care

Craig Stephen

To harm something is to damage it or make it less effective or successful than it was. There are many types of harms to consider (e.g. physical, financial, psychological, ecological, climatological, and others) when managing animals, health, and society. The socio-ecological model of health reminds us that each of these harms can impact the determinants of health as well as each other. Health management needs to address known and existing harms while at the same time minimize the chance of future and unanticipated harms. One Health, EcoHealth, and allied fields have documented how managing one type of harm in one species can lead to harmful implications for other species, populations, or generations. This chapter discusses harm reduction from the perspective of reciprocal care, where we look after ourselves, our community, and Nature over time.

HARM REDUCTION IN A ONE HEALTH WORLD

Health promotion reduces risks, promotes healthy settings, and tends to the underlying determinants of health. Try as we might, we are unlikely to achieve a world of no risk, completely healthy settings, and a full spectrum of supportive determinants of health. Harms still occur. Prohibitions of harmful situations or eradication of hazardous agents can drive the chance of harm to zero, but in their absence, a series of actions are needed to reduce harms.

The central defining feature of the harm reduction approach is its focus on reducing harm. This intentionally obvious description is meant to situate harm reduction within the spectrum of health promotion and health protection scopes of practice. Harm reduction does not argue against eliminating hazards or for accepting them but rather it aims to decrease the negative consequences of the hazardous circumstances in the face of uncertainty and conflicting opinions that prevent eradication of the hazards. Harm reduction is consistent with the precautionary approach that states that lack of full certainty shall not be used as a reason for postponing measures to prevent harm.

Harm reduction is both a goal and a process. It is a goal shared across many health and environmental sciences. Most people interested in health ultimately want to reduce harm to individuals, species, or environments, whether through clinical care, preventive actions, or health promotion. Harm reduction, as a process, focuses on developing local relationships and collaborations for collective actions leading to incremental improvements in health. Reciprocal care harm reduction asks us to consider the interconnections of harms and how actions to reduce one harm influence harms in other species, circumstances, or generations. Harm reduction works to minimize harms through non-judgemental strategies by enhancing skills and knowledge to live safer, more sustainable, healthier lives.

The paradox of promoting human well-being in an exponentially growing human population illustrates the need for reciprocal care harm reduction. The social justice ethic of public health encourages policies that leave no one behind by ensuring all people have equitable access to the conditions and resources needed to be healthy. Political, cultural, and technical advances over the past two centuries have greatly reduced mortality and changed the material conditions needed to bring people out of poverty and improve their well-being. Linking well-being with material conditions resulted in the coupling of well-being to consumption. Increased consumption by a larger proportion of an exponentially growing human population tremendously expanded societies’ ecological footprint, resulting in unprecedented rates of ecological degradation. The World Wildlife Fund’s 2006 Living Planet Index concluded that Earth’s regenerative capacity can no longer keep up with human demand. The drive to reduce harms to people by increasing global health equity has caused serious and, in many cases, irreversible, harms that threaten both current biodiversity and future generations of people, animals, and plants (McMichael. 2002).

Examples of unintentional impacts of harm reduction in one sector causing harm in another can be found in many situations, including the global growth of aquaculture. People in developed countries have been encouraged to increase their consumption of fatty fish as part of dietary strategies to reduce the personal harms from cardiovascular disease. These recommendations fail to consider the reality that global fisheries cannot meet the seafood demands from affluent and developing economies. The collapse of fish stocks can have profound socioeconomic effects on coastal communities, which in turn can shift supplies of local protein that, in some countries, harm terrestrial wildlife (Brashares et al.,

2004). Some countries have looked to aquaculture to reduce harm to wild fish stocks and coastal communities by providing local jobs and meeting the growing human demand for fatty fish without exploiting wild fish. The “blue revolution” of aquaculture has, however, been dogged by concerns about energy-intensive animal production, nutrient pollution, habitat destruction, water diversions that disrupt aquatic ecosystems, introduction of alien species, and the use of fish meals in feeds (Costa-Pierce, 2002). Advice to reduce personal cardiovascular disease risks cannot, in this example, be uncoupled from this web of inter-acting social and ecological harms.

Many One Health issues involve multiple concurrent harms. Chronic wasting disease (CWD) of cervids illustrates this point. This invariably fatal disease of deer, elk, and moose causes wasting, neurological dysfunction and eventual death of infected animals. The Western Association of Fish and Wildlife Agencies in North America deemed this prion disease as a significant threat to the future health and vitality of free-ranging deer and elk (WAFWA, 2017). Because of its similarities to the zoonotic prion disease causing mad cow disease (also known as bovine spongiform encephalopathy), public health agencies advised precaution in consuming cervids known to have the disease or hunted from CWD-positive areas (despite no evidence of human CWD to date). These recommendations discouraged hunting and in doing so harmed rural hunting businesses as well as lowering confidence in consuming wild game for subsistence needs. The resulting food safety concerns had implications for rural food security and on Indigenous rights to access safe and sustainable wildlife. As CWD appears in both wild and farmed cervids, international trade in cervid products was impeded by this disease. What at first was framed as a disease harming individual wild animals was later seen to cause conservations harms, inflict harms to agricultural trade, increase social conflict, cause psychological harm by increasing fear of natural places, alter ecosystem functions as deer and elk populations declined in number, cause cultural harms by discouraging traditional hunting, and create political conflicts linked to debates on how to control this epidemic. A harm reduction process would not focus on eradicating the CWD prion from populations or environments (although recognizing the importance of trying to do so) but rather would rely on existing knowledge, resources, and values to promote collaborative approaches to make incremental gains to reduce ecological, population, or social harms related to the disease.

Harm reduction recognizes that many critical drivers of harm cannot be eliminated. Take for example Japanese encephalitis: a mosquito-borne viral disease that circulates between birds, humans, and pigs. A 2012 study in Nepal sought to control this disease in humans by working with pig farmers to reduce the prevalence of the disease in pigs (Dhakal et al., 2014; Metelka et al„ 2015; Robertson et al., 2013). Because of cultural biases against pig ownership, pig farmers were from poor, marginalized communities. They were often unable to purchase or afford Japanese encephalitis vaccines for their animals. Human vaccine uptake was low in these communities, and mosquito control efforts were inconsistent due to lack of financial resources and distrust of government. Many farmers did not own the land they farmed, causing them to lack infrastructure or financial capacity to house pigs indoors or away from people. Climate change was shifting the distribution of the mosquitoes higher into the mountains, exposing a new cohort of pigs and people to the virus. Policies to increase food security were creating conditions conducive to perpetuating the infection, conditions further compounded by climate change. Culture, poverty, and climate change coupled with an endemic virus were, therefore, the ultimate drivers of Japanese encephalitis harms in this system, but the likelihood that any of these drivers could be changed fast enough and extensively enough to eliminate present-day health and economic harms to families were extremely low. Actions were needed in the interim to reduce harms. In this example, the team focused on improving ecological and personal health literacy to increase uptake of free vaccines and inform agriculture and suburban planning to reduce conditions conducive to the disease but good for the farmers.

Reciprocal care harm reduction operates in a landscape of interacting influences and constantly changing conditions. It must be attentive to the interspecies and intergeneration implications of interventions to prevent or reduce the adverse consequences to all members of the One Health community rather than targeting only the hazard and its human victims. Lessons from managing other complex problems suggest that cooperative approaches that provide insight into cross- sectoral and socio-ecological systems context are critical to working in interspecies health (Head and Alford, 2015). Taking a systems approach to One Health can provide a wider perspective to discover alternative means of solving problems and avoid unintended consequences.

The upstream drivers of health found in social and ecological determinants can greatly influence the persistence, diversity, and magnitude of harms, yet they are most challenging to manage in One Health systems. The inseparable array of factors that determine and modify these determinants, coupled with tremendous challenges in eliminating hazards like pollutants, pathogens, or climate change, suggest that effective harm reduction requires multi-level interventions, ranging from influencing policy to targeted biomedical interventions.

 
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