Richard E. Besser, a physician, is president and chief executive of the Robert Wood Johnson Foundation in Princeton, N.J.

In spring 2009, the H1N1 influenza virus surfaced in Mexico, swiftly evolving from “outbreak” to “pandemic” in just two months. As acting director of the Centers for Disease Control and Prevention at the time, I led our work to issue preliminary warnings and evidence-based recommendations to help Americans reduce their risk of infection — very similar to what we’re hearing about covid-19 today.

Schools were of particular interest given the role children can play in amplifying infectious disease transmission. To reduce that likelihood, our initial recommendation was that officials close schools for two weeks following their first confirmed H1N1 case. The thought was: Keep kids at home, reduce transmission risk — part of an approach called “social distancing.”

Several days later, my phone rang.

Your recommendations are nuts, said David Fleming, the head of public health in Seattle and King County. Social distancing wasn’t happening, he said. Parents without sick leave or affordable child care options were forced to drop their kids at malls, libraries or community centers rather than leave them unsupervised at home. In essence, the CDC had failed to consider that millions of Americans couldn’t comply even if they wanted to. What happens, for example, to the millions of children who get breakfast and lunch through programs at school if we close them?  

Crises such as H1N1 and covid-19 provide a mirror for our society and the actions we take — or fail to take. Today, the United States in that mirror is one in which the risk of exposure and the ability to protect oneself and one’s family depends on income, access to health care, and immigration status, among other factors.

The failures of public policy and imagination have been stalking us for years, creating haves and have-nots: parents who don’t have paid sick leave from work (only 10 states and the District of Columbia mandate it); a lack of affordable childcare or sick child care; at least 28 million Americans living without insurance and nearly one-third of the population still underinsured; health protections that are not distributed evenly from region to region; and fear among undocumented immigrants regarding access to care. 

Even when structural failures could imperil every American, the greatest strains will fall on certain demographics because of their economic, social or health status. The elderly and disabled are at particular risk when their daily lives and support systems are disrupted. Those without easy access to health care, including rural and Native communities, might face daunting distances at times of need. People living in close quarters — whether in public housing, nursing homes, jails, shelters or even the homeless on the streets — might suffer in waves, as we have already seen in Washington state. And the vulnerabilities of the low-wage gig economy, with nonsalaried workers and precarious work schedules, will be exposed for all to see during this crisis. Ask the 60 percent of the U.S. labor force that is paid hourly how easy it is to take time off in a moment of need.

The CDC is an evidence-based public health agency, but if the evidence used to make recommendations does not incorporate these health equity issues, we will fall short. The nation will not be prepared to weather what is becoming a pandemic. If systems and tactics that can help to control the spread of covid-19 — such as paid sick days, shown to reduce the spread of flu in jurisdictions where they are mandated — are not available to every American, CDC recommendations are, effectively, words that cannot be implemented.

Our nation’s predicament today is both tragic, because so many people will likely suffer, and maddening, because it didn’t have to be this way. In the short term, the United States must play the hand that we’ve dealt ourselves. Indeed, there are no short-term solutions to our long-term neglects. The underlying work our nation must do to ensure all people in the United States have a fair and just opportunity for health and well-being — sick leave, universal health care, quality child care and early education, as well as fair immigration policies — must be done in moments of calm.

In the meantime, we could also consider a fund to compensate hourly workers without paid leave for their loss of income when sick; provide legal aid for those who are fired for not coming to work when ill; fund outreach to non-English speakers; ask insurers to waive co-pays for testing and treatment; supplement funding for community health centers that care for a large proportion of those without insurance; and ensure free meals are available for children when schools are closed. 

We don’t know how the covid-19 story will end, but even before the ending is written, we know its lessons. Every long-term solution must be viewed through the health equity lens, for if they are not, we’ll be setting the stage for our next public health failure. To quote a friend, that’s just nuts.

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