Harm Reduction Strategies And COVID-19
Ernest Greene has been working in the adult industry for three decades as a director and magazine editor, most recently of LFP’s Taboo. Hos substantial work of BDSM fiction, “The Master of O,” is available here. In this guest post Greene writes about the adult industry’s response to HIV scares and the formation of Porn Valley’s first testing center, Adult Industry Medical (AIM).
We can beat this thing but first we have to own it.
Okay, starting with the warning labels. This is a very long post – as in 3600 words – about a very difficult subject. It’s likely to prove inflammatory and will, I’m sure, generate comments I’ll have to delete, followed by unfriendings and blockings. Intelligent, thoughtful questions will get thoughtful replies. Anything else gets blasted to electrons on sight.
One of the first things I learned about addressing a plague is that epidemiology is the most political of all medical sciences. Politics are unavoidable in this discussion.
And the politics of this terrible moment have taken a dire situation and made it unimaginably worse. Don’t expect an attempt to give equal weight to dissenting views. Some stories really don’t have two sides.
A nation in crisis led by a malignant narcissist who has disseminated false information, failed to establish an early and effective testing program, refused to issue a nationwide lock-down, squats on The National Stockpile, refuses to mobilize the full capabilities of The Defense Production Act and doles out desperately needed assistance or withholds it based on who flatters his ego does not have the luxury of addressing its plight in a non-partisan manner. He appears unable to grasp the COVID-19 crisis is not reality TV. It’s reality.
And yet his approval rating has ticked up a couple of points and a slim majority of poll respondents think he’s doing a good job of dealing with this crisis. I’d hate to see what they’d consider a bad job.
The division is clear between those who understand and are prepared to act on the science of our common plight and those whose other agendas take precedence.
Korea has tested 270,000 people. In HK they do temperature checks before allowing anyone on or off public transportation. In Israel citizens are limited to 100 meters from their front doors. These responses are in sharp contrast to the confused, uneven and in some instances all but non-existent response in the U.S. As a result we now lead the entire world in the number of COVID-19 cases.
Readers genuinely interested in where we are, how we got here and what we might do to save ourselves have something to learn from an unorthodox source.
What we all need now to the extent it’s still possible is the adoption of a focused, coherent harm reduction strategy on an unprecedented scale. That is just what those in the pariah industry that is porn, of all places, realized in 1997 that this beleaguered nation still lacks overall to its sorrow and the shame of its leaders.
During the AIDS epidemic the entire heterosexual X-rated production industry came within a whisper of extinction but survived with no loss of life and the ability to go forward much as before.
Why were our outcomes so much less devastating than those confronting the larger society now?
Because a very unlikely crew stepped up, took responsibility and did the right thing.
This country’s cruel, ignorant, corrupt president and his inner circle of lackeys and toadies, including his son-in-law (who always reminds me of some half-finished project from the lab on “Westworld”) have not done and are not doing what a bunch of people who make fuck-films managed to see was necessary to save their lives and livelihoods.
It’s not a one-on-one comparison to the menace of COVID-19 but there are applicable parallels, so maybe you want to know how we did and why it succeeded so well. Perhaps you’ll put that knowledge to work in your own life and in the messages you send back to our so-called leaders, because they’re clearly not paying attention to what history taught us.
I am not a doctor and don’t even play one on TV, so I won’t be posturing myself as a qualified expert in the science of epidemiology from a medical point of view. We’ve got Anthony Fauci for that and should all be thankful. I was chairman of the board of directors of the first dedicated testing clinic for sex workers for six terms, active in getting it started and continued to consult to it for a number of years thereafter.
I can only speak from my own layperson’s experience, and that experience tells me we can and should do better in the current situation than we are now. Much, much better.
If Anthony Fauci and the CDC had been fully empowered and if Trump’s gang hadn’t gutted the White House pandemic response unit, we might very well have the mass testing, effective isolation and adequate medical resources without which we’re in such terrible trouble today.
That a nation with only 3,000 bombers in 1939 proved capable of turning out 300,000 bombers by 1945 can’t produce adequate stocks of PPE and ventilators today is a sad measure of how far we’ve fallen since WW2. At the time Pearl Harbor was bombed the U.S. had the world’s 20th largest army. Were we prepared for the war we had to fight? Clearly not, but we got that way in a hurry and emerged victorious.
I wish I could say this lack of early response was wholly unfamiliar but it’s not. Our industry was no more ready for the threat confronting us in 1997 than this country was in 1941. But we too got the message and did what had to be done.
Though the peak of the AIDS epidemic occurred during the 1980’s, the heterosexual porn industry, unlike its gay counterpart, was slow to wake up to the danger it represented to performers and all their outside sexual contacts.
The denial around that threat was not unlike some of the denial about COVID-19 I see every day and hear every time I can bring myself to endure another dismal performance from those supposedly running the show.
There was as far back as 1993, fully 13 years into the AIDS epidemic, a persistent belief that the deadly virus was a concern only to identified “risk groups,” such as gay men and intravenous drug users. It was, in short, someone else’s problem.
As those living in parts of the country where there is still widespread minimization of the threat COVID-19 represents are sadly likely to find out, infectious diseases left unaddressed eventually become everybody’s problem.
It’s all about accountability and lives will be saved or lost according to the assumption of that responsibility by individuals and by government.
For over a decade the het porn business benefitted from a certain amount of demographic luck. Most new performers entering the field during that time came from mid-sized middle-American cities where HIV was still relatively uncommon. If we had drawn talent from areas where it was more prevalent such as New York or San Francisco that luck would have run out sooner but it was inevitable that it eventually would.
If things still seem sort of normal where you are you stand to learn the hard way just as we did that a new normal now will soon arise. Complacency is not an option.
Because I’d been active in the BDSM community since 1983 I’d witnessed the devastation of AIDS from a closer vantage point than a lot of my friends in the adult entertainment industry. I’d seen it sweep through organizations, businesses, social groups and individual lives and knew what an invidious killer it was. Cynthia Slater, founder of California’s oldest and largest BDSM support group died of AIDS. We never had the option of pretending the problem was in someone else’s neighborhood.
By the late Nineties we still had no organized industry-wide screening in porn and the sole test available, the ELISA which has a window period potentially as long as six months during which a person can be infectious and still test negative, was used sporadically only on the initiative of individual performers.
Those who did test did so at private clinics that didn’t share data or produce easily verified uniform results. Mass testing wasn’t even on the table.
Does any of this sound a little familiar? It’s about to get more so.
In 1997 our luck did predictably run out. A single popular male player tested positive at a private clinic and continued to work by showing his partners test forms he’d altered to reflect later dates. Before he was caught, he infected seven of his fellow performers with HIV.
Under mounting pressure from their own attorneys, who could easily visualize the legal and political implications of numerous young people contracting a deadly disease in the workplace, production companies sought some means to address the now-obvious danger to all of us. Universal mandatory testing was reluctantly accepted as the only alternative.
Imagine how much better off we’d all be now if such a program had been adopted all over the U.S. after the first seven cases of COVID-19 had been diagnosed in this country.
Again, our industry had some luck. Right around that time a new test for HIV – the PCR-DNA – that relied on the detection of viral proteins in the bloodstream as opposed to HIV antibodies which took much longer for the body to begin producing – had been recently approved after field trials for general use.
Of course, we have effective tests for COVID-19 but just having a test isn’t enough. You have to use it.
It wasn’t easy to get the first PCR-DNA tests either. We had to fight for them the way the tests for COVID-19 have to be fought for now.
In Los Angeles the new test was available only at UCLA hospital. I did ultimately persuade them to give me the PCR-DNA, though “give” isn’t exactly the right word. It cost $280 and my negative results didn’t come back for two weeks.
Clearly this wouldn’t work on a large scale for a highly mobile community with frequent and multiple potentially infectious contacts.
It took determined negotiation on the part of a doctor whose practice included many in our community to convince a local lab to process the tests overnight, generate standardized results and reduce the price to somewhere around sixty dollars. If and only if we could promise the lab forty tests per day on average they could establish a dedicated processing chain to achieve quicker turnarounds at affordable prices.
Imagine the economies of scale that could have been achieved in this country if President-Art-of-the-Deal had sent forth those fired pandemic unit epidemiologists to negotiate similar arrangements in a unified, nationwide effort sixty days ago.
Which is not to suggest that such a massive undertaking would have been easy or universally popular based on our experience.
Not everyone was quick to board the same train. Back before porn became the corporatized industry it is today, it tended to be anarchic and resistant to collective action. Producers, to state the obvious, are not boy scouts. They were fiercely competitive, given to personal animosities, accustomed to deferential treatment from those who depended on them to make a living and disinclined to be told what to do by outsiders.
And getting performers to accept the expense and trouble of standardized testing was truly like herding cats. Porn performers tend to be young, convinced of their own invincibility and also resistant to adopting standards created by others. Only other performers who understood the danger and how to address it could make the case for harm reduction.
There was then as there is now widespread misunderstanding of what testing for a communicable disease for which there was no effective treatment (in 1997 the miracle of ARV drugs to suppress the development of HIV into full-blown AIDS had not yet come forth) is meant to accomplish.
It isn’t about protecting each and every individual. It is about protecting a whole population. When we finally got our screening clinic up and running, we accompanied each first-time test with a video presentation explaining that a negative result was only good on the day the test was taken.
Even though the window period for the PCR-DNA was only ten days – a huge improvement over the ELISA’s six months – it was still possible to become infected, sero-convert and infect others between tests, which were given monthly at the beginning and later upped to every two weeks.
The program actually worked better than we thought it would mainly owing to the willingness, however grudging, of performers and producers to sign on to it. Because our community was still relatively free of HIV, tests routinely came back negative and some got the wrong idea about how this protected them as a group. It didn’t mean that their working partners were entirely safe on any given day, merely that as of the day their blood was drawn they were infection-free.
What was not widely understood was that our clinic routinely detected about half a dozen “sleeper” cases a month in people taking their first test with the intention of going to work in porn. Testing acted as a firewall to prevent these sleeper cases from slipping through the net.
We were a first line of defense in limiting new infections by discovering existing cases before they could spread into the larger talent pool. In doing so I have no doubt we prevented hundreds of transmissions over the years.
In short, the test told us whom to isolate. Because the numbers of people were comparatively small and geographically limited to the production nexus of The San Fernando Valley the process of testing and excluding those with positive results was remarkably successful.
I do not underestimate the challenge of instituting such measures for tens of millions of people. But because the principles are scientifically sound, they are also scalable if the will and the money are there to undertake the effort.
In the two-plus decades since universal PCR-DNA (now updated to the even more sophisticated PCR-RNA screen) testing was instituted there have been only two decisively authenticated instances of HIV transmission on porn sets. By comparison, Los Angeles County overall has seen an average of nearly three thousand new cases of HIV monthly during that same period.
Is the relevance of our experience not clear by now?
It was never imagined by any of those involved in creating the testing protocols that they would prove one hundred percent effective or that they would reliably protect every INDIVIDUAL performer.
As our medical director put it in stark language, “the purpose of testing is to lower the body count.” When they talk about “flattening the curve” that’s what they really mean.
That is how harm reduction models work and I don’t think that’s been adequately articulated to the country at large precisely because it acknowledges the limits of our ability to protect that country.
Medical professionals aren’t telling us to wear improvised masks to save ourselves from catching COVID-19. Such makeshift measures probably won’t prevent that, given the minute size of corona viruses and their ability to penetrate porous materials. We’re being entrusted with the responsibility not to infect others by reducing our chances of exposing them through our coughs and sneezes.
Harm-reduction, in the absence of treatments and vaccines, is just what the name implies. It assumes that there will be harm and acts to limit that harm to as few people as possible.
Will harm reduction work as a strategy against COVID-19? Preliminary results from China and South Korea suggest that it can – if applied widely enough and combined with effective isolation for those who do test positive and strict shelter-in-place regulations for the rest of us.
Do you trust those at the highest levels to make sure that happens? Nothing I’ve seen so far persuades me to do so in the slightest.
Despite the informed and effective approach evident in some states, at the federal level incompetence and opportunism prevail over responsibility. The skyrocketing death toll and the continued deficits in active measures to keep our medical system from collapsing are evidence of reckless disregard for human life.
Testing on an enormous scale we’re not even close to approaching is an absolute necessity and even if there were a whole lot more of it, testing alone would not be enough.
Only a few behaviors are high-risk for infection where HIV is concerned. Nobody ever got HIV from touching a doorknob. The same cannot be said of COVID-19. We’re just now learning all the ways in which in can be transmitted and one thing we can already see is that, by comparison to many other diseases, it’s gallopingly contagious.
Even if testing becomes generally accessible to all, which remains a huge challenge in itself, those who test negative may take that as a license to abandon social distancing and resume “normal life.” Since they could easily become infectious one week after testing negative this would undermine the whole purpose of the harm-reduction approach.
In short, for that strategy to succeed in this situation we MUST test AND distance And mask until, as in South Korea, nearly all active cases are identified and separated from the public at large.
The densely populated societies in which harm reduction is showing its efficacy provide some constructive examples. But they are also extremely orderly societies in which authorities can employ the HR model uniformly.
Does that description fit our society? Already, despite the warnings of the scientists and healthcare professionals who were on the front lines in the battle against the AIDS epidemic and remain there in the current struggle, we have lost precious time instituting a universal test-and-isolate protocol. That horse has left the barn and run the Kentucky Derby in the U.S., which is how we achieved the unwanted distinction of being COVID-19 Central.
Now the main relevance of testing will likely be in the allocation of resources and the extent to which we can shore up our overstretched healthcare system to address a menace for which we have no more effective weapon than social hygiene to narrow the scope of the catastrophe already in progress.
History is likely to judge harshly those who frittered away the best opportunity to institute the harm-reduction model comprehensively, but that’s no comfort to those who will suffer and die as a result.
If the most apocalyptic scenarios ultimately unfold it will be because the leaders AND the people of this nation failed to do what was necessary. There may be many shortages in the future but one thing of which there will be plenty to go around is blame.
I would be relieved to say I saw the wisdom and determination needed at the top to make sure that ventilators and PPE and test kits are manufactured and delivered where they’re needed most as quickly as possible, but that is not what I see.
Nor do I see the kind of public education required to explain to a frightened nation how the system can and must work and the role each of us must play in making it do so.
Dr. Fauci, much as I admire him, cannot get the signal out over the noise on his own. Neither can his colleagues in the medical community, who risk their own lives daily to save the victims of an unprecedented systemic failure from the top down.
Despite some promising trials, we are nowhere near a generally reliable treatment or vaccine for this ruthless killer.
Until we can develop those things, harm reduction is what we’ve got, and in the places where its operational, such as San Francisco, there is some preliminary statistical evidence to suggest it can work. We need to practice it rigorously, generally, right now and for the foreseeable future, in the full recognition of what it can and cannot do.
It’s too late for us to be Korea. The question is, can we avoid becoming Italy?
Ultimately what made our system in porn effective was accountability. Our employers did not always act out of altruism or concern for those they hired. Some did, but most acted out of self-interest, fear of the consequences and the near-certainty that they would be held accountable for a tragic outcome.
At the same time there had to be individual accountability among the performers. Again, it was the heroic action of the few that persuaded the many to do what was needed.
Until performers recognized their obligation to refuse to work with untested partners even at the cost of a lost paycheck that might be desperately needed to make that month’s rent the project could not have worked.
Both performers and producers were convinced, by no means easily, of the indispensible need for accountability. The performers had to accept accountability for the health of one another and producers had to accept accountability for maintaining the safety of the working environment surrounding them.
And that is the very thing lacking in our national policy, such as it is. No one can hold a leader to account who abuses his power to punish all those failing to kiss his ring with sufficient obeisance. Think for a moment about the cynical message that sends and how that message is amplified through the mean-spirited, conscious lying of right-wing media.
This has resulted in a human disaster largely preventable by human agency if the common sense and common decency to do so had been there.
A disorderly crew of sex workers and their bosses proved persuadable that, as is most often the case, the smart thing to do and the right thing to do coincided.
That this is not understood in the highest halls of power, much less on the streets in a big chunk of this nation, presents us with the greatest threat to our security and prosperity since The Civil War.
Indeed, if the irresponsible, petty, self-involved cabal in charge do not come to their senses and act decisively and patriotically now their earlier failures may result in more deaths than that and every other war this country has fought from its founding. Donald Trump might believe that holding the number of deaths down to a quarter of a million would be proof of success, but what it would really prove is the exact opposite.
There can be no harm reduction without accountability. If the accountability is not stood up the harm is virtually limitless.
It is not too late for harm reduction to work, but much harm has already been done and the hour of reckoning is upon us.
Those in power who fail the accountability test may, by virtue of the advantages of wealth and privilege, face a less mortal fate than those infected as a result of that failure but there will be other consequences from which they cannot hope to insulate themselves.
Countless deaths, a wrecked economy and a nation permanently fallen from its position of leadership in the world will be seen as the responsibility of those who did or did not make the right decisions soon enough if at all.
If we’re going to come through this as a nation we still recognize, we must have testing on a massive scale, centralized monitoring, uniform isolation and social distancing policies with teeth. The full power of our industrial capacity must be devoted to providing our healthcare system with vital resources even-handedly. We must conduct treatment and vaccine research with the urgency of The Manhattan Project.
Above all, we must have an informed public taking it upon themselves to know and do the right thing. Don’t be deceived, like the stock market, that an apparent slowing in the spread of new cases means we’re out of danger. We’ll be at risk for a long time to come and need to dig in for, literally, the battle of our lives.
We must fight the war we have now and harm reduction is our only weapon until something better comes along. From experience, I do believe that war can be won if the common will is there.
It’s on us all, from those in charge to each and every citizen, to own COVID-19 and step up, or it will surely own us.
Previously on Porn Valley Observed: John Holmes And A Brief History of HIV in the Adult Industry
See also: “The Master of O“