Uncomfortable conversations about COVID-19

The relationship between health and income is remarkably clear. Those who are fortunate enough to have higher incomes live longer, healthier lives. The richest among us have life expectancies of more than a dozen years beyond the poorest. The COVID-19 pandemic has laid bare our class divides and points to the imperative of prioritizing health equity as we get past these terrible weeks and months.  

As we describe in “Pained: Uncomfortable Conversations About The Public’s Health,” poverty is a public health problem. The COVID-19 crisis only clarifies the mechanisms by which a new health threat makes the poorest among us the most vulnerable. 

The coronavirus highlights three questions: Who gets exposed? Who needs critical care? Who receives care?

First, economically disadvantaged persons who live in close quarters are likely to get exposed to infected persons around them. A stark example of this kind of exposure risk occurs in prisons, where proportionally the poor are more likely to be housed. A similar risk is seen among the homeless or those transiently housed in the U.S. These are the sites of repeated outbreaks, exacerbating the spread of COVID-19.  

Add to this exposure risks associated with the inability to protect oneself due to financial reasons. While guidance to prevent the spread of coronavirus includes wearing gloves and masks, not everyone can afford to do so. After all, nearly half of Americans have less than $400 in savings; they might not have money to spare for such protective equipment.

Unlike wealthier people, whose jobs allow them to work from home, those economically disadvantaged may work outside the home in order to pay their bills, take public transportation to jobs that don’t offer paid sick leave, fill positions where they are least able to protect themselves from exposure and possible infection, sort and deliver packages, serve as cashiers and drive buses. Often, they are forced to choose between going to work sick and staying home hungry. 

Second, research shows those with lower incomes are more likely to have chronic underlying diseases, which appear to increase the chances of developing more serious COVID-19 infections. The poor are not only more likely to smoke and suffer from asthma and other lung disease, but they are also more likely to suffer from diabetes and obesity. Patients who have one or more of these chronic diseases are at an increased risk of needing hospital-level care if they contract COVID-19.

Third, the poor are more likely to be uninsured or underinsured than the wealthy, which makes them think twice about costly testing or seeking prompt care when symptoms are only mild. At the same time, thousands of safety-net health clinics serving the poor face closure. Our lack of universal insurance leaves those in poverty with no place to go for life-saving treatment. 

These distinct issues that disproportionately affect the poor, all of which antedated COVID-19, will live on past this pandemic if we are not attentive. COVID-19 has exposed the vulnerability of our poorest neighbors, which has been perpetuated by deep, long-lasting societal injustices. 

COVID-19 has magnified and compounded basic problems of food and utility costs, of increasing rents and limited urban housing. Our newest health problem sits atop our oldest economic issues, which are part of America’s shameful disregard for the most vulnerable amongst us.  

What can we do today in the midst of the current coronavirus pandemic? We help the struggling. We find housing for the homeless. We guarantee all workers job-protected paid sick time that can be used immediately or for a future emergency. We disallow evictions and foreclosures until months after this crisis ends. We mitigate financial ruin just as we mitigate viral spread. As the medical sector has risen to unimaginable challenges, our policy-makers must do so too, moving quickly and demonstrating a focus on health equity. 

We shouldn’t accept what we’ve been settling for. America’s poorest are imperiled, but they shouldn’t be — even after this pandemic is contained. We must do better.  

Michael Stein, M.D., and Sandro Galea, M.D., are the authors of the new book, “PAINED: Uncomfortable Conversations About The Public’s Health.”