The pandemic is widening social and economic divisions that also make the virus deadlier, a self-reinforcing cycle that experts warn could have consequences for years to come.
By Max Fisher and Emma Bubola
DMITRY KOSTYUKOV FOR THE NEW YORK TIMES
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 is 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 A. Errett, a public health expert who co-directs a center on extreme event resilience at the University of Washington. “Pre-existing social vulnerabilities only get worse following a disaster, and this is such a perfect example of that.”
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 pre-existing 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.
ImageA garbage collector resting in Tehran on Saturday. Crises like the coronavirus can deepen the gap between the haves and have-nots.
A garbage collector resting in Tehran on Saturday. Crises like the coronavirus can deepen the gap between the haves and have-nots.Credit...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.
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As a result, people at the lower ends of society are about 10 percent 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 over 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.
In Italy, some workers, like Lorena Tacco, who works at a factory near Milan, have gone on strike over their employers’ failure to establish what they consider sufficient health protections as the epidemic spreads.
“Who cares about the workers’ health, while the rich run away,” she said. “But then poor people, who need to bring bread home, go out and take risks.”
Domenico Marra, who works at the same plant, said fear of the outbreak was rampant there. He worries about carrying an infection back to his children, particularly a daughter who has a weakened immune system.
“We do want to work, but we are scared of going home, we are scared to touch our family,” he said.
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.” 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, says he is selling off assets before letting drivers go.
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, Mr. Sakamoto says 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 coronavirus can deepen the gap between the haves and have-nots.
A London supermarket on Sunday.Credit...Andrew Testa for The New York Times
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.
“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, more even than catching the coronavirus, that her son’s school will reopen before she gets work, bringing gas and school lunch bills she cannot afford.
Unequal access to health care in any country makes getting sick especially expensive for the poor.
In the United States, 90 percent of people whose income is in the top quarter have paid sick leave at work, while only 47 percent of those in the bottom quarter do.
Last year, 26 percent of Americans deferred health care because they could not afford it, one Gallup poll found. In another survey, one in four said someone in their family had skipped a doctor-recommended test they could not afford, and one in six 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 study in the United States found that state-mandated sick day policies reduce the spread of an influenza epidemic by up to 40 percent. 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 one in five 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
Though 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 three in 10 workers with H1N1 symptoms to continue going to work, the study found. The researchers concluded that this behavior drove a staggering 27 percent 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.”
Picking up children from school in New York City last week. City officials say shutting down schools there could leave tens of thousands of homeless students without hot meals.
Picking up children from school in New York City last week. City officials say shutting down schools there could leave tens of thousands of homeless students without hot meals.Credit...Gabriela Bhaskar for The New York Times
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, Dr. 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.
Longer-term consequences are coming into view. New York City officials have said that closing local schools would leave many of the system's 114,000 homeless students without hot meals or medical care.
Even small pockets of mutually reinforcing poverty and ill health make everyone more susceptible.
Research conducted during an influenza outbreak in New Haven, Conn., found that the rate of infection nearly doubled in census areas where a high proportion of residents live below the poverty line.
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.
“Public health isn’t just about your own personal health, it’s about the health of the public at large,” Dr. Errett said. “If there’s one person who can’t get treatment, that person is posing a risk to everyone.”
Max Fisher reported from New York, and Emma Bubola from Milan. Reporting was contributed by Makiko Inoue, Hisako Ueno, Eimi Yamamitsu and Motoko Rich from Tokyo.
Max Fisher is a London-based international reporter and columnist. He has reported from five continents on conflict, diplomacy, social change and other topics. He co-authors The Interpreter, a column exploring the ideas and context behind major world events. @Max_Fisher • Facebook