Part of this developing crisis is very well known: On December 31, 2019, Chinese officials reported a cluster of pneumonia cases in Wuhan and identified the novel coronavirus as the causative agent on January 7, 2020. This novel coronavirus spread rapidly, and on March 11, 2020, the World Health Organization declared COVID-19 a pandemic. To date, there are more than 1 million confirmed cases in the United States and 3.5 million worldwide.
Through this all the virus has terrified the world, in no small part because of a sense that we are all at risk, that the virus is non-discriminating, and we can all get sick. That is true, but it is also not the complete truth. Once again, as with all other health conditions, those who are most at risk are those who are already vulnerable by way of the social and economic disadvantage that characterize their lives.
A fundamental driver of our health, and our risk of contracting COVID-19, is socioeconomic status. There is abundant evidence that socioeconomic status is associated with multiple dimensions of health and that those with poor socioeconomic status have lower life expectancies. Socioeconomic status affects where we live, what we eat, what type of job we have, and whether we have access to health insurance and high-quality healthcare. All of this, in turn, determines our health. Socioeconomic status in the US is also inextricably linked to race and ethnicity. Persons of color are disproportionately represented among persons with lower income or less education, representing a shameful legacy of racial and ethnic segregation throughout American history.
These socioeconomic conditions influence our risk of contracting COVID-19, just as they affect nearly all other health indicators. Housing conditions, for example, can dramatically influence our risk for contracting COVID-19. Poor housing conditions often result in decreased sanitation (e.g. rodents, insects, mold), overcrowding, and decreased ability to physically distance; these factors all increase risk for transmission of COVID-19. Jobs that require in-person attendance make physical distancing difficult, and these jobs are commonly worked by the economically disadvantaged. Further, many people with lower incomes rely on public transport for job attendance, thereby increasing physical contact and risk for COVID-19 transmission.
Immigration status affects housing conditions, type of employment, access to health insurance and high-quality healthcare, and more. Immigrants disproportionately work jobs that require in-person attendance with minimal pay, often requiring public transportation to report for job duty. The chronic stressors, or allostatic load, of living and working as an immigrant in America, particularly in the current political situation, is enormous, making immigrants at high-risk for COVID-19 infection and serious complications.
Socioeconomic status and employment influence the type of health coverage individuals have and the attendant health consequences of COVID-19. Persons with health insurance are more likely to have a primary care doctor they can call about COVID-19 concerns or to present for medical attention if they develop COVID-like symptoms.
And while social factors influence our differential risk of contracting COVID-19, the risks accumulating from the economic fallout from this pandemic are perhaps even more influenced by these social factors. Physical distancing results in a punishing economic set of consequences that principally affect those who are already vulnerable. For example, hourly wage workers tend to have lower pay than salaried workers, less job security, and are less likely to be able to work from home. For non-essential hourly wage workers during shelter in-place ordinances, this amounts to no paycheck. No paycheck results in our society’s most vulnerable populations unable to pay for rent, utilities, food, and other necessities for themselves and their families, which in turn is associated with poor health on multiple dimensions.
We can also expect the economic downturn to have a disproportionate impact on women. The National Women’s Law Center reports that women are typically paid 82 cents for every dollar paid to men, and this gap is even greater for Black, Latina, and Native women. Notably, women are on the frontlines of the COVID-19 pandemic. For example, 93% of childcare workers, 88% of registered nurses, 85% of home health and personal care aides, 70% of restaurant servers, and 66% of grocery store clerks are women. It is also important to note that women are at significantly increased risk for intimate partner violence due to physical distancing measures, including emotional, financial, physical, and sexual violence.
It falls on all of us at this moment to bear witness to the fact that the most vulnerable in our society prior to COVID-19 are now the hardest hit by the pandemic. This calls for a health equity lens to our approach to COVID-19, which must include economic policies that alleviate the financial and health costs of the measures we have put in place to mitigate COVID-19. Approaches to level the playing field, that put social forces at the heart of policy initiatives to address COVID-19, should be a priority at all levels of government in the weeks and months ahead.
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Rebekah L. Rollston, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Clinical Associate at Tufts University School of Medicine, and Resident Affiliate at the Harvard Medical School Center for Primary Care.
Sandro Galea, MD, DrPH, is a physician, epidemiologist, and author, and is dean and Robert A. Knox Professor at Boston University School of Public Health.