Pandemics highlight global inequalities, from who is educated about a disease to who can afford a visit to the doctor if they get sick, to who can work remotely—or even take time off work—to recover and prevent the spread of the disease to others. Health officials have said it’s inevitable that America will see an outbreak of COVID-19, the novel coronavirus that was first reported in Wuhan, China, and has since spread to more than 60 countries, infecting more than 88,000 people so far.
As it continues to spread, it’s not enough for health officials to advise people to work remotely or self-quarantine if they display flu-like symptoms. An equitable response to coronavirus has to take into account the systemic issues—and the vulnerable populations those issues create—that could keep some people from receiving treatment.
Who gets treated?
We’ve already seen how pandemics can exacerbate disparities. The 2014 Ebola outbreak primarily affected low-income countries that didn’t have access to sufficient health infrastructure or education resources. Not only were those already disadvantaged populations disproportionately affected by the disease, the countries were even further disadvantaged because of the millions they spent on containment and recovery (Sierra Leone spent $67 million on healthcare and disease mitigation), the hits to their economic growth from trade reductions, and the effect of high health worker deaths on an already insufficient healthcare system.
Within the United States, the privatized healthcare system means that if you think you might have contracted COVID-19, you might not be able to afford the test that confirms that, or the days off necessary to prevent you from infecting others. A Florida resident who went to a hospital for coronavirus testing when he had flu-like symptoms after traveling back from China got a $3,000 bill. New York state, at least, has taken steps to prevent this; Governor Andrew Cuomo announced a directive this week requiring New York health insurers to waive cost-sharing for coronavirus testing, including emergency room, urgent care, and office clinics. (The Trump administration is reportedly mulling over a similar national proposal.)
The actual process of testing in the U.S. has also come under fire for tight restrictions on who qualifies for a test and how limited the CDC has been in its testing capacity (though that appears to be changing). Contrast this to South Korea, where “drive-thru” coronavirus testing facilities are open to the public and take less than 10 minutes; the country can process 10,000 tests a day.
But an equitable response to coronavirus goes even further than access to testing. In an open letter to Vice-President Mike Pence and other federal, state, and local leaders from the American Civil Liberties Union, more than 450 public health and legal experts outlined necessary elements to a fair, and effective, COVID-19 response.
Protecting the uninsured
“One of the greatest challenges ahead is to make sure that the burdens of COVID-19, and our response measures, do not fall unfairly on people in society who are vulnerable because of their economic, social, or health status,” they write. The extent of a U.S. coronavirus outbreak, they add, depends on four key things: adequate funding, mitigation of public fear, fair management of what will be a surging healthcare demand, and the necessary resources for a fair control of the infection.
Government funding is crucial to managing a public health concern, and not only in terms of the funding for COVID-19 specific resources, such as testing. “It has to be new funds that don’t cannibalize the existing support systems that are critical to our public’s health in the long term,” said Yale University law professor Amy Kapczynski on a press call hosted by the ACLU concerning the public letter. “It’s also critical that important governmental activities are not interrupted, especially those that protect the vulnerable. Government needs a plan at all levels to prioritize essential services and support to the public, for example, to ensure that Social Security and vet benefits continue to be provided.”
It’s also important that officials enable the public to follow their recommendations for care and prevention actions, and a big part of that is making sure healthcare facilities are immigration enforcement-free zones. “There’s been a wide number of reports over the last few years of immigrants and people in mixed-status communities foregoing healthcare, avoiding doctors and hospitals prior to this outbreak,” said professor Wendy Parmet, Center for Health Policy and Law Director at Northeastern University, who also signed the ACLU open letter. “If that trend were to continue during the outbreak, it would have consequences not simply for the individuals themselves, but also for the greater public health.” Immigrants also make up a significant proportion of the workforce, particularly in places like nursing homes, so protecting that public means protecting the people who care for them.
The U.S. healthcare system is “not particularly well set up to dealing with a pandemic,” she said, and to break down insurance and cost barriers to health access, the experts advise policymakers to work directly with insurance companies to ensure affordable access, even for those who are uninsured, much like what New York has instituted. The New York directive doesn’t directly mention the uninsured, but does note that New Yorkers receiving Medicaid will not be expected to pay a co-pay for any COVID-19-related testing.
Making it affordable to call in sick
Those recommendations to the public to stay home from work or self-quarantine if sick also need to be backed by a comprehensive plan that includes social and economic support, in order to make those options truly available to all. “Those who have to self-isolate or care for sick family members or kids staying home school will not be able to do this without adequate income support,” Kapczynski said. “We need to direct resources to individuals to allow them to cooperate with the public health response.”
In Washington state—one of the hardest hit in the U.S., where at least nine people have died from COVID-19 so far—nonprofit Working Washington has outlined what employers and government officials can do to protect service workers who often can’t take sick time. They’re calling on employers to waive policies that require a doctor’s note and allow employees to “go negative” on sick time, and on the state to end the backlog for processing paid family and medical leave claims and make those benefits immediately accessible to workers, especially those who have to stay home to care for kids during school cancellations.
So far, though, the U.S. seems to be lacking such resources. After Walmart released a memo to all U.S. stores that noted the CDC recommendation to stay home if sick, Walmart employees said that they’re afraid to use their sick time because they could be fired or lose the chance at a future bonus. “In the face of the coronavirus, we’re worried that Walmart’s punitive sick time policy will lead to people coming to work when they’re contagious,” United for Respect leader and Walmart employee Melissa Love said in a statement. The MTA is barring transit workers from wearing masks, and though masks aren’t recommended as a preventative measure, the decision to remove that option has frustrated employees who want the option, and who don’t feel the agency has their safety in mind.
Other countries are taking, and have previously taken, more comprehensive measures: Hong Kong officials pledged HK$25 billion (more than $3 billion) in cash handouts to businesses and vulnerable groups affected by the coronavirus outbreak. With schools closed in Japan, Prime Minister Shino Abe vowed to provide subsidies to help working parents care for their kids. During the 2003 SARS outbreak in Canada, the government provided loss of income compensation for those who had to be quarantined or had to miss work to care for someone with SARS.
Even with support, there will still be vulnerable populations, mostly those living in close quarters, from nursing homes to prisons. “We should be considering not only how to effectively control transmission and treat people who are incarcerated, but how to get our policing policies to support public health, recognizing, for example, that jails can help amplify an epidemic,” Kapczynski said.
And throughout every action, it’s crucial officials don’t stoke any scapegoating. Early reports of the coronavirus linked a fear of the disease to why Chinese restaurants were losing business. In Korea, one religious sect, the Shincheonji church, has been at the center of the outbreak, and that stigma has prevented some people from seeking testing. Pandemics have a history of discrimination and that stigma can follow vulnerable communities. It’s important, Parmet said, “to make clear that this is a disease that’s not particular to any ethnic group, racial group, that we are all in this together, and that discrimination and scapegoating of any kind is deeply counterproductive.”