Coronavirus proves inequality is a public health threat

A few years ago, an acclaimed PBS series asked: “Is inequality making us sick?” (Yes.)

The coronavirus forces us to ask belatedly: “Is inequality a public health threat?”

Yes.

Public health crises call for individuals to make sacrifices for a common cause. But radical inequality makes sacrifices required much greater for some who are excluded from common benefits, eroding ethical and practical foundations of emergency response.

Americans are advised to stay home from work, school and public gatherings. To wash hands and attend hygiene assiduously. To adopt social distancing. To stay home if sick. To seek medical care promptly if mild flu symptoms suddenly worsen.

But these recommendations are impossible for many Americans to follow. We depend on providers of essential services to continue work, while hourly and gig workers lose all income if they don’t. Low-income workers without sick-leave may not be able to pay the rent if they stay home. The homeless have no running water or sanitation, and gather in close encampments for safety. The uninsured, under-insured, and undocumented face risks pursuing medical care.

A public-private partnership is being launched to increase testing capability. Testing is important to evaluate the sick, distance carriers from well, and monitor the epidemic. But many Americans who have symptoms or known exposures may avoid testing. They may perceive testing as more risky than beneficial if they doubt they will receive care but fear forced quarantine or other coercive measures. If enough Americans fear testing, efforts to contain the virus will be impeded.

Strikingly, coronavirus has hit in the midst of a national conversation on health care reform. The outbreak underscores that access to primary health care is a public health necessity.

An ounce of prevention is worth a pound of cure. That is particularly true for coronavirus which spreads easily, and snowballs rapidly in the minority of cases that progress from mild to acute. The uninsured are not the only ones who may shy from testing and treatment important to others as well as to themselves.

Many Americans through no choice of their own have highdeductible health plans adopted by employers or private insurers to reduce costs. By design those plans encourage people to wait before seeking care. Immigrants including both undocumented and documented have been discouraged from seeking care through Medicaid or community health centers by the new public charge rule (which penalizes immigration applicants for use of public services). Meanwhile, more affluent or fully insured Americans who don’t think twice about costs are clamoring for access to testing and medical evaluation — some appropriately, and some as “worried well” who burden health systems in times of emergency.

In the short run, emergency response must reduce barriers to testing and treatment of the vulnerable and actively engage them. It should provide the basic means of following public health recommendations to all — running water, testing, safe quarantine, and treatment. It should compensate those most financially hurt by following public health recommendations. Response can be successful only if mindful that everyone is in the general population.

In the long run, we must integrate two moral languages that weaken each other when compartmentalized: social justice, and the common good. Health care for the vulnerable — frail elderly, the homeless, immigrants and refugees, the unand under-insured — is often described as a social justice issue. Conversely, pandemic planning is often framed by the ethical challenge to protect the common good. But social justice is intrinsic to the common good. And the common good cannot be advanced without social justice.

It has taken the coronavirus to remind us that humanity really is all in one boat.