Moral Shaming: "You do You"

One evening last September, Gavin Yamey, professor of global health at Duke University in Durham, North Carolina, dined indoors and tweeted a selfie of himself and his two tablemates—Chris Beyrer, director of the Duke Global Health Institute, and Gregg Gonsalves, a Yale epidemiologist and global health activist who won a MacArthur genius grant for his work on AIDS, global health, and social justice. Gonsalves has long been a voice for the vulnerable and disabled. Throughout the pandemic he lofted the torch of COVID caution and precautions, including masking, testing, vaccine boosts, and better ventilation indoors. He has been unafraid to critique those he regards as COVID minimizers, including President Biden himself (as in an article for The Nation, “No, Joe Biden, the Pandemic Is Not Over”).

Dining indoors these days certainly isn’t news. But within minutes, Pandora’s box had been flung open—unleashing an online tsunami of calumny directed entirely at Gonsalves. It was a moral condemnation of his life, his decency, his very self, based on this single, public act. Mike Hicks, one of Gregg’s online critics, summed up his view this way: “Does it make sense to engage in low-risk behaviors for 90 or even 95 percent of the time so you feel justified sticking a revolver to your head and pulling the trigger in a game of COVID Russian roulette?”

The reaction reveals a level of moral outrage increasingly entering debates over public health. For Gonsalves, it is concerning. “After three years of a pandemic we have to think about what’s sustainable,” he responds. Expecting responsible behavior from others is reasonable, but asking for totally, completely flawless behavior 100 percent of the time is not. “An absolutist moral framework pits us against each other and takes the public out of public health.”

We are now in the “You do you” phase of COVID-19, but that may be nothing new. Medical anthropologist Martha Lincoln of San Francisco State University notes that America has a long tradition of framing individuals as the most influential actors in their own lives, and this lets regulators off the hook. “We are reduced to looking to individuals as the major cause of and culprit for the outcomes that we’re living with,” she explains. “Diverting responsibility from institutions such as the CDC or the White House means that we can’t really locate a common enemy, and so enemies appear to be potentially everywhere. People may experience catharsis from identifying those who seem to be straying from the behaviors we think are correct. But it’s counterproductive.”

Instead of focusing on individuals, adds Gonsalves, “more lives can be saved when we shift the environmental and structural factors of society that throw us into the path of risk. The entire debate about individual interventions deals with downstream effects. Yes, individual interventions save lives, but they leave the larger sources of sickness unaddressed. It’s a ruse.” An analogy he likes to use is this: If you’re standing on the shore of a river watching hordes of people flailing as they drown in a fast current, you can either jump in and save one, or go upstream where you find the bridge has collapsed and needs to be repaired.

In America today, most of us are standing on that metaphorical shore, trying to decide whom to save from or blame for infection, climate change, staggering health care costs—one, two, ourselves, everybody, nobody? Moral frameworks about health can slide into our lives almost unnoticed and ignite self-righteous outrage as well as deeply felt betrayal, grief, or contempt. The result is more than toxic in today’s world, when so many engage in what molecular biophysicist Joseph Osmundson calls “these online clusterfucks of shaming, which never work anyway. Morality is so baked into our language of illness, it is almost the default setting, the language given to us to think about sickness,” he says. “It takes active, thoughtful work every day with every sentence one uses to reframe illness in ways that don’t make it a moral state.”

A powerful sense of right and wrong, of justice and injustice, forms early in life. Research has shown that toddlers as young as two are capable of judging what is fair and unfair. We may acquire an internal moral grammar in lockstep with the acquisition of actual language. But when moral frameworks spill into the realm of public health, we end up with what bioethicist Euzebiusz Jamrozik and his collaborator Steven Kraaijeveld have dubbed mismoralization.

Mismoralization is exactly what it sounds like—the misapplication of the moral impulse in places where it does not belong and cannot help. Mismoralization in public health can lead to shaming, blaming, and ultimately the fracturing of society. “Across societies,” write Kraaijeveld and Jamrozik in an August paper in Medicine, Health Care and Philosophy, “human beings are inclined to punish norm violations.”

“We as a culture don’t think about how policy makes people sick,” says medical historian Jim Downs, author of the book Maladies of Empire. “We’re much more willing to ask, ‘What did YOU do to become sick?’ As soon as you hear someone has lung cancer, the first question is ‘Do you smoke?’ That’s a moral question.”

At its worst, mismoralization leads to criminal sentences. Thirty-five U.S. states still have laws that criminalize exposing others to HIV, even though AIDS is now a preventable and treatable disease. In some states, the maximum jail sentence is still life in prison.

On the other side of the coin, getting infected with HIV has also been moralized. “I cannot count the times I’ve been told I brought HIV on myself because I couldn't keep it in my pants,” says Gonsalves. “I deserved what I got.” Even now, he says, he occasionally gets emails and direct messages calling him things like “an AIDS-infected f%#@*t.”

During the 1980s and 1990s, when HIV infection and mortality rose and peaked, there was a kind of moral calculus that went like this, says Osmundson: “Did you get it from a monogamous partner who cheated? Well, that’s bad but not that bad. Did you get it at a sex party? Oh my God, you should be ashamed.”

If you didn’t wear a condom back then, you were seen as killing yourself and others, adds Liz Highleyman, a medical journalist specializing in HIV and other infectious diseases.

Last summer, when monkeypox swept largely through gay communities—most often transmitted, it appeared, during the physical intimacy of sex between men—old stigmas resurfaced. One epidemiologist who caught monkeypox told the Philadelphia Tribune that he was afraid people would think, “If you got monkeypox, you got it in a very slutty way.” Public health officials applied harm reduction principles that had proved effective in the fight against HIV, says Highleyman, but the public response was not so forgiving. As one tweet put it: “So Big Brother shut down your churches and businesses for Cov19, but won’t tell gay men to stop having orgies for monkeypox.”

When confronting illness or frailty, this tradition of moral outrage does not recognize the systemic failures that are the true drivers of illness. “United States history has often featured the criminalization of infection,” observes medical ethicist Harriet Washington, author of the book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present, which won the 2007 National Book Critics Circle Award for Nonfiction. Pellagra, for instance, was called a Black infectious disease that struck “African Americans because of their supposed penchant for living in filthy conditions.” It was actually a disease of malnutrition that largely afflicted the enslaved. It wasn’t until the 1920s that physician Joseph Goldberger discovered that the illness stemmed from nutritionally inadequate corn-based diets. Later researchers learned that the disease is due to a deficiency of the B vitamin niacin.

When the higher SARS-CoV-2 infection and death rate of African Americans was first documented, many causal theories tended to blame the victim, says Washington. She explains that some health officials asked whether higher drug or alcohol use, disparate genetics, or failure to don masks and shun crowds heightens Black Americans' risks. Others, she says, invoked Blacks' high obesity rate, although obesity is an American problem, not a racial one. "In any event," says Washington, "obesity in African Americans is tied to living in “food swamps” where a dearth of affordable nutritious fare is worsened by saturation of tobacco and alcohol products whose marketing is targeted to racial groups."

Tuberculosis, a scourge caused by Mycobacterium tuberculosis, surged in widespread epidemics in Europe and North America during the 18th and 19th centuries. Once it was understood to be an infectious disease, the sickness was moralized. Women and the poor were targeted—the former for apparent failures in keeping their houses clean, thus allowing tuberculosis to spread; the latter for living in squalid conditions that favored transmission and threatened the rest of society.

Early in the COVID-19 pandemic, a hundred Asian Americans were being attacked in this country every day, according to Washington. “People initially shun, exile, and then want to kill others who may be perceived as carrying dangerous infections.” Washington says this is an example of protective prejudice based on the fact that we are indeed more vulnerable to novel pathogens.

The principle is correct, but the application is often misguided. In the late 1800s, for instance, coastal West Africa was called “white man’s grave” because European soldiers and missionaries, exposed to infections to which they had no established immunity, died in high numbers there. Similarly, Native Americans succumbed to the strain of syphilis brought to the New World by European settlers. But where outbreaks of infection are concerned, “majority groups wrongly demonize minority groups,” Washington says, “avoiding them and then expelling them.”

We have a long tradition in this country of shifting blame to those who don’t deserve it. As anthropologist Lincoln points out, in almost every domain in American life where public health is at stake, large industries reflexively move their own responsibility out of view. For instance, nearly 60 years ago, a young lawyer named Ralph Nader wrote Unsafe at Any Speed, proving that car crashes were not caused only by “bad drivers“ but also by the auto industry’s unwillingness to spend on safety features like antilock brakes and airbags. During their long legal battle with the Justice Department over the opioid epidemic traced to its drug, oxycontin, Purdue Pharma and its owners, the Sackler family, shifted blame onto the individuals who became unwitting addicts. "Abusers aren’t victims; they are the victimizers," Richard Sackler stated in one email. And the fossil fuel industry has long popularized the concept of an individual’s “carbon footprint” as a way to shift attention away from its own excesses—while individuals are left homeless from the wildfires, hurricanes, and vicious storm surges that are now commonplace effects of a changing climate.

These days it is the individual who is just plain tired of our current pandemic. That may be the case, but it does not constitute the basis of a valid public health response. It’s a form of manufactured futility that can be self-fulfilling. “A tired public is not an argument for public health policy,” says Lincoln. “So I understand why individuals are blaming other individuals. We all feel we’re trying to resolve a national public health crisis ourselves at home or online.”

What can we do to cope? First, recognize that “humans are gloriously messy,” says Osmundson. “We make mistakes, and there is no moral failing to wanting to have dinner with friends, eat pie when we’re on a diet, or have sex once without a condom. We have to build systems that are robust enough that these deeply human behaviors don’t lead to bad outcomes.”

If you lower your mask to take sips and bites at a wedding, should you be willing to go to jail for manslaughter, as queried in this tweet? If you insist that everybody wear a mask, are you robbing others of the opportunity to “richly connect, to fall in love, to live a full life”? Or are we shadowboxing to fill the vacuum left by the public health agencies that guide our national decisions—the CDC, the FDA, and the White House that presides over them both? “It’s not rocket science, what people need at a population level,” says Osmundson. “We need free health care, paid sick leave, an infrastructure that tackles public health head-on, and policy that reflects the fact that we function as a global superorganism.”

While we are nowhere close to that nirvana, we can stop hurling the slings and arrows of moral outrage at one another and join hands to demand more of our institutions, now and in the future. In that sense, we do have a moral obligation, for we are, as Gregg Gonsalves often says, “our brothers’ and sisters’ keepers. Even in our human imperfection, that’s all we’ve got.”