As Coronavirus Deepens Inequality, Inequality Worsens Its Spread



Alessandro Grassani for The New York Times

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As the coronavirus spreads across the globe, it appears to be setting off a devastating feedback loop with another of the gravest forces of our time: economic inequality.


In societies where the virus hits, it is deepening the consequences of inequality, pushing many of the burdens onto the losers of today’s polarized economies and labor markets. Research suggests that those in lower economic strata are likelier to catch the disease.


They are also likelier to die from it. And, even for those who remain healthy, they are likelier to suffer loss of income or health care as a result of quarantines and other measures, potentially on a sweeping scale.


At the same time, inequality itself may be acting as a multiplier on the coronavirus’s spread and deadliness. Research on influenza has found that in an epidemic, poverty and inequality can exacerbate rates of transmission and mortality for everyone.


This mutually reinforcing cycle, experts warn, may be raising the toll of the virus as it widens the socioeconomic divides that are thought to be major drivers of right-wing populism, racial animosity and deaths of despair — those resulting from alcoholism, suicide or drug overdoses.


“These things are so interconnected,” said Nicole Errett, a public health expert who co-directs a center on extreme event resilience at the University of Washington. “Preexisting social vulnerabilities only get worse following a disaster, and this is such a perfect example of that.”

“这些事情有很大的相互关联,”华盛顿大学(University of Washington)公共卫生专家尼科尔·埃里特(Nicole Errett)说,她是一个研究极端事件发生时社会韧性的中心的联合主任。“一场灾难过后,原有的社会脆弱性只会变得更糟,这次疫情就是一个完美例子。”

Because each low-income family forced to accept a higher risk of exposure can infect others, she added, the consequences of inequality, while most obviously felt by the poor, “put the broader society at risk.”


How Inequality Worsens the Coronavirus


Two major risk factors are thought to make the coronavirus deadlier for those who catch it: old age and preexisting health conditions.


But a body of research points to a third: low socioeconomic status.


Even for those well above the poverty line, studies find that low income relative to the rest of society is associated with higher rates of chronic health conditions such as diabetes or heart disease.



Arash Khamooshi for The New York Times

This has not always been the case. As inequality has risen, health disparities have widened. Preventive care and health education have steadily tilted toward the educated and the well-off.


As a result, people at the lower ends of society are about 10% likelier to have a chronic health condition.


Such conditions can make the coronavirus up to 10 times as deadly, according to recent data from the Chinese Centers for Disease Control and Prevention.


Taken together, these two statistics suggest that COVID-19 can be about twice as deadly for those along their society’s lower rungs.


At the same time, people with lower incomes tend to develop chronic health conditions between five and 15 years earlier in life, research finds.


Put another way: Health organizations have said that people older than 70 are at drastically greater risk of dying from the coronavirus.


But the research on chronic health conditions suggests that the threshold may be as low as age 55 for people of lower socioeconomic status.


Those numbers capture only a sliver of the ways that inequality can make the coronavirus deadlier.


In China, many workers are employed informally and so cannot count on social services if they take time off — especially those in service jobs that require regular contact with other people. As a result, the people who can least afford care are often at greatest risk of transmission.


Government-imposed shutdowns, like those announced by France and Spain this weekend, do come with some worker protections. But small businesses will probably struggle to keep paying employees beyond any guaranteed sick days, particularly those in retail or other sectors that cannot work from home.


In Japan, which has some of the lowest inequality of any major economy, people with jobs such as taxi driving enjoy a degree of security that rarely exists in other countries.


In Italy, in contrast, taxi drivers — already struggling on hourly wages undercut by the rise of ride-hailing services — scour for fares amid the outbreak.


“I have got a mortgage, bills and groceries to pay,” said Andrea Arcangeli, a taxi driver and father of two from Rome. “I can’t stay home.”

“我有房贷要还,有账单要付,还得买吃的东西,”家住罗马的出租车司机安德列亚·阿尔坎杰利(Andrea Arcangeli)说,他是两个孩子的父亲。“我不能呆在家里。”

He said he had made only 18 euros — about $20 — in a day’s work.


At the Nihonjo Taxi Company in Osaka, Japan, cabbies have a modest guaranteed monthly income, and the president, Atsunori Sakamoto, said he is selling off assets before letting drivers go.

日本大阪的日本城计程车株式会社(Nihonjo Taxi Company)的出租车司机每月有不高的基本收入保障,社长坂本笃纪(Atsunori Sakamoto)说,他正在出售资产,之后才会考虑解雇司机。

Still, even in Japan, these lower rungs of employment are hit harder than their white-collar counterparts. While office workers telecommute, with little fear of losing their jobs, Sakamoto said that if business does not pick up in a few months, he may have to let drivers go.


How the Coronavirus Worsens Inequality


When inequality is high, the cost of living tends to rise, forcing more lower-income families to live paycheck to paycheck. At the same time, the decline of labor unions and the rise of part-time work means that low-income workers have fewer protections.


As a result, crises like the coronavirus can deepen the gap between the haves and have-nots.


Lara Fulciniti, a waitress in a suburb of Milan, was barely covering her mortgage and car payments before the epidemic hit. As hourly work evaporates, she has fallen behind.

米兰郊区的女服务员拉拉·富尔奇尼蒂(Lara Fulciniti)在疫情暴发前只能勉强支付房贷和车贷。随着工作小时数的减少,她已经无力偿还这些贷款。

“I am not ashamed to say I did not pay my bills this month,” she said. “I had to choose between those and groceries.”


She fears, even more than catching the coronavirus, that her son’s school will reopen before she gets work, bringing gas and school lunch bills she cannot afford.



Andrew Testa for The New York Times

Unequal access to health care in any country makes getting sick especially expensive for the poor.


In the United States, 90% of people whose income is in the top quarter have paid sick leave at work, while only 47% of those in the bottom quarter do.


Last year, 26% of Americans deferred health care because they could not afford it, one Gallup poll found. In another survey, 1 in 4 said someone in their family had skipped a doctor-recommended test they could not afford, and 1 in 6 said that someone in their family had skipped prescribed medication.


Health experts fear that these costs will accelerate outbreaks, particularly as stories circulate of four-digit bills for coronavirus testing or treatment.


This can affect everyone. One U.S. study found that state-mandated sick day policies reduce the spread of an influenza epidemic by up to 40%. Most states have no such policy and could see far more infections as a result.


Labor inequality and poor workplace protections may exacerbate the spread of norovirus, a highly contagious stomach bug. Research by the Centers for Disease Control and Prevention found that 1 in 5 food service employees went to work while sick with vomiting or diarrhea for fear of losing their jobs if they stayed home, turning restaurants into vectors for norovirus outbreaks.


Such conditions may have severely elongated the H1N1 epidemic in the United States, which killed 12,469 Americans in 2009 and 2010, according to a study by the Institute for Women’s Policy Research.

根据美国妇女政策研究所(Institute for Women’s Policy Research)的一项研究,生病后不敢休假可能严重延长了H1N1型流感在美国的流行,2009年至2010年流行的H1N1导致12469名美国人死亡。

Although public health officials had urged social distancing — also a cornerstone of coronavirus prevention — spotty access to health care and the economics of part-time employment led 3 in 10 workers with H1N1 symptoms to continue going to work, the study found. The researchers concluded that this behavior drove a staggering 27% of all infections.


The Pandemic Inequality Feedback Loop


When a health crisis hits entire segments of society, it can set off a cycle in which declining economic status leads to rising rates of chronic illness. That, in turn, further depresses productivity and raises health care costs, leading to more poverty, which leads to more disease.


According to a 2010 study by a British biological sciences journal, Proceedings of the Royal Society B, whole communities can become caught in a “disease-driven poverty trap” in which “the combined causal effects of health on poverty and poverty on health implies a positive feedback system.”

英国生物科学期刊《皇家学会学报B辑》(Proceedings of the Royal Society B) 2010年发表的一项研究显示,整个社会阶层可能陷入一个“疾病导致的贫困陷阱”,在这个陷阱中,“健康对贫困的因果关系以及贫困对健康的因果关系暗示着一个正反馈系统”。

Families reliant on hourly work are already running out of money, forcing many back out to look for jobs. Because communities tend to cluster by economic status, Errett said, the people who are both at the greatest risk of infection and likely to suffer most from the virus are all in proximity, multiplying the risk.


Because diseases do not respect the barriers that separate rich from poor, health inequality is a problem for everyone. A study from Delhi, India, one of the world’s most economically polarized cities, found that its slums served as citywide accelerants for an influenza outbreak.



Gabriela Bhaskar for The New York Times

“Public health isn’t just about your own personal health; it’s about the health of the public at large,” Errett said. “If there’s one person who can’t get treatment, that person is posing a risk to everyone.”