The Poor and Marginalized Will Be the Hardest Hit by Coronavirus

 We need to rethink our public health strategies before the next outbreak—even if the conversations are uncomfortable

Scanning electron microscope image of the virus that causes COVID-19. Credit: NIAID Flickr (CC BY 2.0)

In recent months, the novel coronavirus COVID-19 has emerged as a health challenge of international concern. As of this writing, there have been over 111, 350 confirmed cases of the disease, including over 3,890 deaths. In the US, there have been over 500 cases and 22 deaths.

Much is still unknown about COVID-19. It is clearly unnerving to have a novel coronavirus causing disease and death worldwide, and the scale of the outbreak in some places has been truly frightening. Yet, as new cases are reported, it is worth noting that there is reasonable epidemiologic doubt as to whether COVID-19 is as dangerous as some public comments have suggested. As with any public health challenge, it is important to keep COVID-19 in perspective, our response measured, guided by cutting-edge data and our best science. Having said this, any number of deaths is, of course, concerning, and it is undeniable that we are living in a moment of real anxiety.

Central to our collective task at this moment is to support the work of those who are charged with protecting the public’s health. It is with that in mind that we would do well to recognize and assist the federal and local health officials in charge of outbreak control, and ensure the conditions are in place to generate the science that can inform these efforts. 

And yet, while difficult, it is also necessary to pause and reflect on how we arrived here. What can this outbreak teach us, so that we can be better prepared for the next one? And there will be a next one. The only questions are when and where, and will we have learned the lessons of the present challenge, so we can more effectively address what lies ahead? I realize in some ways that it almost seems too soon to think of the next event, but perhaps there is merit in such reflection at a time when our thoughts are sharpened by the present challenge. Perhaps we can then commit to investing in a future where we do not repeat the mistakes that have led us to this moment.

To my thinking, the core lesson of COVID-19 is the need to change the context in which it emerged, a context of disinvestment in public health preparedness. We tend to focus on public health preparedness episodically, spotlighting it in times of challenge and neglecting it when we feel our vulnerability has diminished. As a consequence, we simply do not have the money invested in a health system that can scale up detection and treatment in time to adequately deal with large-scale outbreaks. This reality has been somewhat mitigated by the dedicated health professionals who are working to address COVID-19.

But the fact is, these professionals, and the populations they serve, are not receiving adequate support. The Trump administration has worked to dismantle disease security programs, and cut funding for global health initiatives that would have positioned us better to meet the challenge we now face. The administration initially requested $2.5 billion to address the coronavirus, and has since signed an $8.3 billion spending bill for dealing with the disease. These are necessary funds, yet they would have been far more effectively spent on preventing outbreaks like COVID-19, rather than responding to them after the fact. Early in his term, President Trump famously hung a portrait of Andrew Jackson in the Oval Office. He might have considered another American leader, Benjamin Franklin, who said, “An ounce of prevention is worth a pound of cure.”

Yet disease prevention is about more than health systems, as critical as they are. Preventing disease means attending to the conditions from which poor health can emerge. In particular, it means acting when these conditions create pockets of marginalization that put certain populations at disproportionate risk of disease, as we have seen during this outbreak. Older populations, and people with preexisting diseases, are at greater risk of dying from COVID-19. Obesity-related conditions, for example, seem to worsen the effect of this disease.

The Centers for Disease Control and Prevention (CDC) reported that people with heart disease are at higher risk of COVID-19 complications. In the U.S., the obesity rate is about 42 percent, a status quo informed by a range of factors, including poverty, urban design, larger portion sizes and agricultural subsidies that make unhealthy food the default fare for those who cannot afford to improve their diet. All this we can, and should, address.

The other key COVID-19 risk factor, age, has grown central to our country’s demographic trajectory. Each day, another 10,000 people in the U.S. turn 65. When it comes to supporting aging populations, we are still far from a world that helps older individuals age well. We do not invest nearly enough in nursing homes or the caregivers who support the aging. We are especially unprepared to support our aging rural population.  

All this has created poor health which is compounded by COVID-19 and will be compounded by the next infectious threat if we do nothing to improve matters. The challenge is that we are almost willful in our ignoring of the conditions that underlie health. While COVID-19 has focused us on these conditions, we should not make the mistake of turning away once we feel the threat has passed. Preparing for the next outbreak means building a society that is truly healthy, one where health inequities do not act as ready-made vectors for each large-scale infectious threat.   

And, it is perhaps worth noting that a healthy society is also one that addresses all its epidemics, not just infectious threats like COVID-19. We should not forget that the U.S. is in the midst of an opioid epidemic, which contributed to 70,237 drug overdose deaths in 2017, and a gun violence epidemic, which killed 39,429 people last year, and over 7,000 so far in 2020. We have also seen up to 52,000 deaths from flu since October.

None of this is intended to minimize this new coronavirus or the concern it evokes. It is just to say that we should be talking about health all the time, not just when we feel it is threatened. We should talk about, and fund, robust health systems capable of detecting and responding to epidemics. And we should talk about the conditions that underlie these systems, that shape our health each day: the context of our lives. Food, schools, investment in the aging, a fair economy, an end to marginalization—such factors are at the heart of health and should be the focus of our national debate.

At this time of challenge for health, we would be remiss indeed if we did not use this moment to build a healthier world, by learning the lessons of the coronavirus and putting them into practice.       

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