“The Most Dangerous Strain”

Abstract

Socioeconomic inequities have direct implications in COVID presentation, severity of illness and prognosis. From practice of prophylactic measures to availability of personal protective equipment, from access to diagnostic tests to treatment resources, there are many facets and distinct disease processes of a virus that, among many things, serves to expose and highlight our global disparities.

Whoever said “Coronavirus doesn't discriminate” must not be aware of the impact of inequity in the health-disease process.¹ This familiar pattern of bias,² chronically correlated with outcomes, becomes even more exposed in times of crisis.

Whoever said it doesn't discriminate is ignoring that, much more than an infectious disease, this is a socioeconomic and cultural illness, its victims too many too count; its treatment, at this point, only palliative.

Whoever dared to mention that this viral pandemic does not discriminate is neglecting the populations at risk— the poor, the marginally employed, the people of color. People unable to perform hand hygiene because they don't have access to plain soap or treated water, or to exercise social distancing because being six feet apart from another person is a luxury they do not have. They're neglecting the brutal reality of more than half a million homeless Americans, 35% of which are unsheltered, the number gradually increasing as shelters are being closed as people get sick.³ These people have historically been more susceptible to health problems, particularly communicable diseases. Even in their mortality will they remain undervalued, as testing and resources are scarce. They must remain on standby as asymptomatic politicians, celebrities and professional athletes jump to the front of the line.

They're not considering how social disparities render people profoundly vulnerable to medical issues, particularly in a pandemic. They're unaware that, according to the International Labour Organization, informal labor comprises more than sixty percent of the world's employed population.⁴ They're disregarding important cultural aspects, like the fact that there are 18 million domestic workers in Latin America alone, where a culture of quasi semi-slavery still prevails. High society relies on maids for virtually any chore, yet they fail to provide decent labor rights or guarantees. Ironically, this is the same dominant class that returned home to Latin America after trips to Asia, Europe and North America, bringing back more than their luggage. Their servants continuing to work or be dismissed without pay, waiting to contract the virus. Contrary to what happens to their employers, access to diagnostic tests and treatment does not apply to them. Adding another layer of tragedy to their situation, they live in highly populated areas and rely on public transportation to commute to and from work, completing the dreadful recipe for contagion.

They're also disregarding the fact that minorities have been consistently hit hardest by this virus, such as the black population of Chicago, whose death rate is nearly six times greater than that of white residents.⁵ In Louisiana, it accounts for 70% of deaths though only make up 32% of the population.⁶

They're ignoring data that shows that White Americans are twice as likely as African Americans or Latinos to have the option to work remotely, and that higher rates of job loss will occur among poor Americans, dragging over twenty million people below the poverty line and leaving them unable to feed their families.⁷

Whoever said that Coronavirus does not discriminate has forgotten that the war to acquire personal protective equipment (PPE), ventilators and anything related to the armamentarium to fight this illness has gone to the highest bidder or the most politically influential.

COVID-19 is not an equal opportunity pathogen. It heavily discriminates all around us.⁸

I look at the three brand new intensive care units my institution recently built just to treat COVID patients. I see their well-trained, well-equipped nurses and physicians displaying fancy isolation gowns, masks and respirators. I see the ease with which our patients get tested and receive good medical care. In addition to genetic code, zip code is a response determinant. And in all those things I see how this virus discriminates.

I see colleagues, friends and acquaintances working from their comfortable, spacious homes with a home office and a new computer with novel technology that allows them not only to keep their jobs but also to remain productive.

Sometimes, while I'm working, I get interrupted by my kids for a question about their online schooling activities. I then think of the millions of children who don't have access to any of that— academic growth, technology, socialization or even food, like the 114,000 homeless students in the New York City school system who are now left without hot meals.⁹ Children who now spend their days in the emptiness of what society has attributed to their value.

In the safety of my home, I think of all the people for whom staying home represents the least safe option: women and children victims of domestic violence, now condemned to spend their days locked with their perpetrators. Increasing rates of domestic violence have been reported across the globe. In France, there has been a 30% increase and in Brazil the number is even higher. In China, domestic violence is reported to have tripled during their shelter in-place mandate.¹⁰ It is noteworthy that these numbers are likely underrepresented as many victims are deprived from any contact with the outside world.

I see my refrigerator stocked up with healthy, plant-based cuisine thanks to my grocery store's curbside pickup. Then my thoughts shift to those working so tirelessly at local markets with minimal protection or recognition, another testament to massive discrimination.

The United Nations Development Programme¹¹ recently forewarned the impact on inequalities that will emerge from this crisis and how it will translate into economic consequences that will further distance the racial wealth gap. Very soon, it will become obvious how this pandemic is disproportionately felt among the most vulnerable segments of society and how our privilege will continue to dictate the course of health and sickness.

“An imbalance between rich and poor is the oldest and most fatal ailment of all republics.”, said Plutarch (circa 46–120 CE). In 2020's crisis du jour, we remain hostage of our refractoriness.

Declaration of competing interest

The authors have no conflicts of interest.