Choice dominates the discourse on #covid19. But lack of choice drives the epidemiology. A few thoughts on conversations around “choice” (and shaming) in the context of #covid19.

Poor choices are highly visible. The unmasked grocery store visitor. The neighborhood party. The #covid19 denying in-law or college student. These stories occupy a large part of our social media feeds and collective imagination as we watch an epidemic curve head due north.

Yet, we avert our gaze from the lack of choice. The essential workforce carrying on in restaurants, factories and shipping facilities. The crowded apartment holding two families. The fatigued workers ferrying between three skilled nursing facilities.

It’s easy for us to see “poor choices” when we do glimpse at those most vulnerable to #covid19. The protruding nose in a steamy kitchen. The television set purchased with a relief check. The smoke break in a back room of a nursing home. “If only they..,” many a message reads.

Contact tracing may find a path to a living room or factory breakroom. Any serious examination of epidemics finds that disease choose people, or “preferentially selects” for those with constrained choices, as Paul Farmer would remind us.

My work in global health has taught me that cataclysmic health events—preventable deaths from infectious disease, childbirth, and injuries—often involve a collision of non-choices. People deprived of real choices colliding with similarly starved systems.

Look further back and we can see the historical forces that have constrained choice—intergenerational poverty and violence, the long legacy of colonialism and structural racism, conflict and forced migration, shifting economies, neoliberal policies.

Recognizing the confluence of non-choice that often culminates in #covid19 might lead us to a sort of sorting into binary categories. The covidiots and the covictims. Those that deserve our empathy and those that we should shame on their behalf.

Shaming though, as @JuliaLMarcus has said far more eloquently, is toxic to public health. What we see as “poor choice” represents a spectrum of unmet need. Some of those needs can be readily met; others are structural and resist simple solutions. https://twitter.com/julialmarcus/status/1327305367253037061?s=21

Our collective pleas for “good choices” may be expressions of moral distress, trauma, or grief. Our calls to #maskup and stay home may affirm our actions (or deny our needs)—but blind us to the fact that most are already home and lead us to give up on those who cannot stay home.

Is there #covid19 noncompliance? Does it spread disease? Do the actions of those with choice have cascading effects on others? Do we not have collective responsibility? Of course, and we do.

Yet, the literature on shame as an effective public health strategy is thin. I’ve checked. There’s a much larger body of evidence though on the ways structural inequities drive epidemics. Let’s redirect some of our energy to thinking about how we can act on it.

Retreating to a parochial focus on individual behavior and #covid19 shaming represents a form of pandemic nihilism to which we cannot succumb. This virus will give up. Let’s not give up on a vision of public health that seeks to expand the universe of choice before it does.