Americans have reason to be hopeful: The United States has some of the best doctors, nurses and hospitals in the world. It spends more per capita on health care than any other country and has capable scientists and front-line workers trained in emergency preparedness. But our underlying deep-seated social and economic inequities are likely to create unique vulnerabilities here. Add to this the current political climate — with low trust in institutions, skepticism (even disdain) for science, the expansion of anti-immigration policies and “post-truth” narratives — and we may have a recipe for disaster.
Epidemics emerge along the fissures of our society, reflecting not only the biology of the infectious agent, but patterns of marginalization, exclusion and discrimination. The United States has many open wounds rooted in decades of racist policies and the criminalization of poverty. The coronavirus is likely to reveal deep failures and reinforce existing health inequities.
Just looking at key statistics that make this country “unique” among its peer wealthy nations should make us worry and consider who is likely to be most harmed. Almost half of Americans between the ages of 19 and 64 have inadequate health insurance. Many may avoid seeking care because of the potentially devastating financial burden. Despite the wealth of this country, close to 13 million children are living in poverty. Around 2 million Americans, including a significant number of Native Americans living on reservations, live without running water and basic indoor plumbing, hindering access to our most important prevention tool: hand washing. And over 2 million Americans — a disproportionate number of them people of color — are incarcerated, often forgotten in emergency preparedness plans and left particularly vulnerable because of overcrowding and poor conditions.
Epidemiologists know that it is not only the risk of contracting an illness that matters, but also the subsequent likelihood of death or recovery. Mortality rates from covid-19, the disease caused by the coronavirus, appear to be highest among the elderly and those with preexisting health conditions such as cardiovascular disease, diabetes, chronic respiratory disease, high blood pressure and cancer. Because Americans, on average, are not as healthy as our peers in wealthy countries, we may expect a higher fatality rate here. If this becomes a widespread outbreak, such an epidemic would probably be most devastating for the poorest Americans and for communities of color, who already are dying at younger ages and at higher rates from these common conditions. And sadly, we can expect that if there is widespread exposure and the health-care system is overstretched because of the coronavirus, these same Americans will also die at higher rates from unrelated conditions.
The polarized political climate makes the threat posed by those long-standing inequities far more dangerous. At least three social phenomena have intensified in recent years, all of which could easily make the epidemic worse here: growing mistrust of institutions and science and an acceptance of “alternative facts”; a widely held belief in individual responsibility for disease prevention and a social solidarity gap; and a spike in anti-immigrant sentiment and “othering.” Combined, these trends create unique vulnerabilities for the United States.
In public health emergencies, uncertainty always poses a challenge for communicating about risk. There are clear principles for transparency and simple, consistent messaging of known facts that help reduce rumors and panic, but in a post-truth era, at a time when “alternative facts” are being embraced as equally valuable, promoting public health is particularly challenging.
We have already seen the impact in the recent resurgence of measles. The announcement that all messaging by government health officials and scientists on the coronavirus will be coordinated by the office of Vice President Pence may be an effort to reduce panic and confusion. But with a limited number of trusted messengers, Americans may be less informed and less likely to accurately assess the risk.
By controlling the message of scientists, the government may discourage an already mistrusting population from heeding public health guidance critical in slowing the spread. And there are troubling reports that some police departments are creating fake warnings about coronavirus-contaminated methamphetamine to trick people into coming forward, enabling arrests.
Americans typically frame emergency preparedness as individual preparedness. But in this case, as face masks and hand sanitizers disappear from shelves and online vendors, containment will not be achieved just by individual acquisition of the right commodities or by technical action such as widespread testing for evidence of infection.
Containment is not only about science and equipment. It’s about people and collective action. Success is rooted in social solidarity. Some of our best prevention strategies, such as adhering to quarantine or covering one’s cough, are designed to reduce transmission rates, not necessarily to protect an individual but to protect the most vulnerable in the community. Weeks ago, the World Health Organization warned of a global shortage of face masks, which are critical for front-line health workers. The situation is only going to get worse. Hoarding behaviors, which may be rational from an individual perspective, are often counterproductive for community health.
Finally, widespread anti-immigrant sentiment, fueled in part by recent policy changes and statements, could be a particular Achilles’ heel here. More than 10 million undocumented immigrants may be too afraid to access medical treatment, and millions of documented immigrants, especially those from Asia, may be reluctant because of the stigma and discrimination they could face.
To reduce exposure, people with the virus must come forward. They must also identify their contacts. Fear that this may result in deportation or harm for loved ones may make this essential step impossible for many. As we learned during the Ebola and Zika responses in New York City, without the active engagement of immigrant communities that have the closest ties to the countries with the highest burden, prevention efforts could falter.
We don’t mean for this analysis and its grim outlook for what lies ahead to create additional fear or panic in the United States. Indeed, there is much to be reassured by: For many young, healthy Americans, as well as children, the risk of serious illness and death is low, and health departments across the country are accurately assessing risk and implementing prevention measures.
Yet at the national level, we need an intentional, human-rights-based response that pays attention to health equity. This will require honest conversations about the potential human rights challenges posed by quarantine and other measures as well as more discussions about the ethical distribution of limited resources. It may also require some self-reflection on how policies can have unintended consequences for public safety and public health.