Intended for healthcare professionals

Opinion US Covid-19 Lessons

Building harm reduction into global health security and pandemic prevention

51app 2024; 384 doi: (Published 20 February 2024) Cite this as: 51app 2024;384:q301

Read the full series: US covid-19 lessons for future health protection and preparedness

  1. Saskia Popescu, assistant professor1,
  2. Jessica MalatyRivera, senior adviser23
  1. 1Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
  2. 2Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
  3. 3deBeaumont Foundation, Bethesda, MD, USA

As countries sift through lessons from the covid-19 pandemic and work to reduce vulnerabilities that led to over 773 million cases, nearly 7 million confirmed deaths (estimates of excess deaths are around 28 million), and $12.4tn in global economic losses, it is vital to think beyond the traditional mechanisms of response and preparedness.123 Global health security—the proactive and reactive efforts of countries to prevent, detect, and respond to infectious disease threats—is a critical component of such protections.

In the United States and elsewhere, global health security requires not just prevention and preparedness efforts but also building resilience capacity in critical infrastructures to reduce harm from emerging threats. Resilience to biological events (bioresilience) is the capacity of a society to quickly respond and recover from outbreaks or emergencies. Recent outbreaks such as covid-19, mpox, Ebola, and measles suggest that our traditional approaches to managing and recovering from public health crises need to be re-evaluated to fit the increasingly interconnected, polarized, and complex communities we live in.

Health security has traditionally included work related to pathogen early warning systems, bolstering vaccine development, and therapeutic research. While these efforts are important, social interventions such as prioritizing science communication, combating misinformation or disinformation, and funding harm reduction are often an afterthought. We recommend not only making the existing focal points as agile and robust as possible but also integrating social interventions such as harm reduction into these toolkits and metrics for global health security and bioresilience.

One of the most important but often neglected lessons from recent outbreaks is the importance of harm reduction—a public health strategy for modifying behaviors that increase risk of harm. Used successfully in the 1980s for sexual health education in efforts to reduce teenage pregnancies and transmission of HIV and sexually transmitted infections, harm reduction strategies have since been applied to other behaviors, such as substance abuse.

Applying harm reduction

Harm reduction is not a single method but rather a series of tools and public health interventions to help improve health through safety and dignity—in short, it incorporates empathy and reduces stigma to help guide individuals towards safer behaviors.4 Harm Reduction International, a non-governmental organisation focused on drug misuse, describes it as “policies, programmes and practices that aim to minimise the negative health, social and legal impacts associated with drug use, drug policies and drug laws . . . It focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that people stop using drugs as a precondition of support.”5 Examples include needle exchange schemes and provision of naloxone to reverse overdoses.Furthermore, harm reduction serves as a critical tool to improve education and awareness and to help guide decisions informed by risk awareness and mitigation, rather than shame.6 Using harm reduction strategies can counter the effect of stigma, which is a main hindrance for response to health crises such as that of opioid addiction.78

Harm reduction methods have also become increasingly important in outbreak response. During the 2022 mpox outbreak, harm reduction was used to inform people about how to reduce their risk, sharing ways to have safer sex with awareness for mpox, such as forming limited groups (sex pods), avoiding new partners, watching case levels, and integrating more clothing. Strategies included targeted public facing communication for gay and bisexual men that used graphics and messaging such as, “forget slutty summer, hold off for anal autumn!”9 During the 2014-16 Ebola outbreak in west Africa, harm reduction efforts focused on safer and dignified burial interventions but also on community education that addressed fear and stigma around Ebola survivors.10

Harm reduction has often been used to fill critical gaps in government response, especially in vulnerable communities. More recently, it was highlighted during the covid-19 pandemic as a multidisciplinary tool to combat misinformation and strict social abstinence policies.11 Harm reduction tools to increase awareness of risk and mitigation strategies together with effective risk communication had an important role in community use of non-pharmaceutical interventions such as moving activities outdoors, social bubbles, and mask wearing. Community based health groups also made use of harm reduction in the 2022 mpox outbreak. For example, the Rapid Epidemiologic Study of Prevalence, Network, and Demographics of Mpox Infection (RESPND-MI), initiated by queer and transgender activists in New York city, provided resources such as information on vaccine availability as well as critical epidemiological data.12

Use of harm reduction strategies in public health emergencies has helped create better informed and more resilient communities. Their application will be vital as the world deals with more complex and nuanced global health threats such as climate change, infectious disease spillover, antimicrobial resistance, and biosecurity breaches from biomedical research. Global pandemic prevention initiatives like the Global Health Security Agenda and the World Health Organization’s Preparedness and Resilience for Emerging Threats call for a more holistic approach to mitigating infectious diseases threats, and including tools such as harm reduction will be necessary for whole-of-community disease mitigation, prevention, and resilience. In this period of pandemic reflection and recovery, our ability to integrate social interventions will ultimately affect our future response and resilience during public health emergencies.


  • Competing interests: We have read and understood 51app policy on declaration of interests and have no interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • This article is part of a series commissioned by The 51app (). The guest editors were Ana Diez Roux and Gavin Yamey and the lead editor for The 51app was Jocalyn Clark.