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. Per-
haps the most well-known are the “pro-choice” and “pro-
life” 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 reduc-
tion.” Since no one could possibly advocate for increasing
harms, you might be surprised to hear how very contro-
versial 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 controver-
sial, 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 elim-
inate the risk of disease, but to mitigate the effects of in-
herently 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 activ-
ities. 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 libertar-
ians. In fact, given these examples it might seem that harm-
reduction 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 hin-
dering 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 harm-
reduction programs today. Instead, harm-reduction pro-
grams are running into much more vocal, and effective, op-
position 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 under-
stand 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 bat-
tles 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 reli-
gious 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 pre-
vention (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 men-
tioned 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 re-
search 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 Asso-
ciation, 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 re-
creation 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 pro-
grams? 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 be-
haviors are biologically driven or otherwise immutable, no
3. “We’re an empire now, and when we act, we create our own re-
ality. 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 http://blogs.salon.com/0003379/2004/
12/17.html (accessed April 6, 2005).
4 ajob
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 public-
health programs science-based or are they based on mal-
leable social behaviors? The answer, and the reason the bat-
tle over harm-reduction programs will never be completely
resolved, is that most public-health measures are, inextri-
cably, 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 needle-
exchange 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 re-
ligious 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.
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.
March/April 2005, Volume 5, Number 2