COVID-19: The “Great Equalizer”?
Talk about a Great Misnomer. On the day before this new decade, the world received reports of a novel coronavirus emerging in the Wuhan province of China. For a few days and weeks, we watched as the numbers of cases climbed and became worried as the first deaths were announced. More or less, we sat by and watched China deal with this problem, and while epidemiologists and public health experts pointed out the warning signs early on, countries like the US and UK had taken few if any precautions by the end of January (and even February…)
Cases grew in number and we watched the red circles on the Johns Hopkins map grow larger - cropping up in east Asia, and then Italy, Spain, and now the largest ‘dot’ in the United States.
In March we started to stay home - at least, those who could afford to. And we tuned into key figures, celebrities, ‘influencers’ as they shared their thoughts and entertained us on social media. When issuing warnings and promoting caution about the disease, many called COVID-19 a “great equalizer.” This virus doesn’t care about your socioeconomic status or race, they say. We’re all in this together. And we’ll come out the other side stronger. America always rises to the occasion when healing from hardship or tragedy.
But COVID-19, and any other disease, like most things, is NOT blind of wealth, race, and gender. This pandemic is not the great equalizer, because in reality it shines a spotlight on our disparities and widens those gaps - within communities and across countries. And the course of the pandemic in New York has exposed the part of the extent of these inequities.
What may be the least surprising, particularly in America, is the influence of wealth on health. From prohibitively high costs of health care to the ability to take sick leave, health is invariably intertwined with money and experiences with COVID-19 have been no different. There are so many examples of this, but one that has been infuriating for me personally has been watching the role celebrity, fame, and/or money can have in access to diagnostic testing. While the US (and UK) struggle to test suspected and even symptomatic cases, often encouraging citizens to remain home and self-treat, in the first few weeks of March we saw a number of announcements from asymptomatic celebrities announcing their 'positive' test results. This list included actors such as Idris Elba and politicians such as Rand Paul. If tests are in such high demand, how are asymptomatic A-listers accessing them while others remain self-isolated in fear of infecting others? This issue may not be the one to 'break the camel's back' in terms of COVID-19 response, but I do think it's worth mentioning. (Let's also not forget the many wealthy people live-streaming from their mansions asking others to donate to COVID-19 causes while few of them have put money where their mouth is -- caveat: I know there have also been some great celebrity donations, but also $100,000 is less than 1% of their net worth).
What's more important is the influence of wealth on our ability to take care of ourselves and loved ones. It is easy to take 'shelter in place' policies for granted. Many individuals, in the US and around the world, simply cannot afford to sit still. In cash economies like India or most communities in Africa, mobility is money. It is not so easy to just stay home and the ability to work remotely is a privilege. In the bottom 25th percentile of income in the US, just 9% of the population could potentially work from home according to US Labour Statistics. Additionally, many low-paying jobs that are still essential during these COVID-times (think: grocery and restaurant industries) are not guaranteed sick leave. In fact, only 12 states in the US mandate paid sick leave, and these policies are sure to come with caveats. Between decreased operational hours for work and the risk of needing time off to care for one's health or another's, this population is disproportionately affected.
Another disparity that has only recently made headlines this week has been the disproportionate effects based on race. This is surprising given racial disparities in regards to health have been relatively established - for example, data on pregnancy deaths in the US linked to differences in race. However, it is also possible that this data in regards to COVID-19 has only recently been disaggregated and analyzed to the point of showing significant results. One of the most obvious examples is Milwaukee County, Wisconsin where the total population is 26% Black and yet African-American make up half of the confirmed COVID cases and 80% of the deaths. One of the best descriptions I've read of this was on a Twitter thread yesterday. It's easy for some to blame these differences on behavior - health-seeking behavior, available income, etc. But @aatkeson puts it best: "These are not differences, coincidences or 'because Black people have higher rates of certain diseases.' It is because structural racism drives health inequities."
A third factor easily overlooked is the varying impact this disease (and again, other health emergencies) has on gender. This is multi-fold:
1) Biology: We already know there are sex differences in the biology of the human body, and therefore how we respond to diseases, etc. Interestingly, COVID-19 data shows higher mortality for men. But majorly lacking in the US response is consideration of these differences to inform vaccine research, response policies, and more. It is so vital we track and disaggregate this data (as well as race). If we do not know how and to what extent this disease impacts different sexes, how do we develop an effective response and treatment?
2) Workforce & Leadership: Over 70% of the health workforce is women, and yet in the US they hold fewer than 20% of leadership roles. This is also reflected in the uneven inclusion of women in COVID-19 response taskforces around the world.
3) Caretaking: One impact of health emergencies that can be overlooked is the impact if unpaid care work on women. Typically "child care, elderly care, and housework fall on women." In the case of caring for an infected individual or family member, this can also mean an increased risk of transmission.
4) Violence & Health: Health emergencies that stretch the health system impact women by decreasing access to sexual and reproductive health services, pre- and post-natal care, and other services such as domestic abuse support. There have been many many reports about increases in domestic abuse since the beginning of the pandemic due to the conditions that have risen (time at home without being able to leave - just to go outside or to seek help). Other concerns include a rise in "sexploitation" - for example, landlords in Hawaii pressuring women unable to pay their rent due to lost income.
This just skims the surface of some of the reasons why gender cannot be overlooked in the planning and implementation of pandemic response and relief efforts. When analyzing all the available speeches and public statements made by the political leaders of Finland, France, Germany, New Zealand, the United Kingdom, and the United States throughout the month of March - I was surprise to find that the consideration of gender and the unequal impacts this pandemic has was not mentioned once. However, this week the UN released an incredibly comprehensive brief on the impact of COVID-19 on women.
Finally, I just want to touch on the 'war' metaphor that has become so entwined with our discourse about this disease. A pandemic is not a war. The virus is not the enemy. And the answer is not victory because of the warriors and fighters involved. A rampant spread of disease is so much more than this - at the same time it is completely out of our control and completely influenced and manipulated by our actions. Language with connotations that this is a war to be won and that you just need to 'fight' is misleading and inhumane by implying that those who are impacted - those whose lives are lost - were not strong enough and were simply a casualty. This kind of rhetoric is not okay, and it is even more inappropriate when we recognize the imbalanced and inequitable way this disease affects different populations.
You may recognize this from a previous post and if you've seen my Twitter feed you will not at all be surprised by this choice (I have purchased three copies in the last year). This book follows the first hand accounts of an Irish diplomat and a British doctor working on the frontlines of the 2014-2016 Ebola outbreak in Sierra Leone. is absolutely imperative reading for anyone trying to understand what it means to respond to an epidemic and it does a particularly great job of acknowledging the importance of recognizing the humanity of those impacted by such a health emergency.