Social distancing puts most vulnerable for health disparities at risk
When the World Health Organization (WHO) upgraded COVID-19 to pandemic status, we rose to the call, beginning to practice social distancing. But, this leaves the poor and those already at the highest risk for health and other disparities at greatest early risk.
In the midst of a pandemic where undoubtedly many lessons history taught us will be relearned, we must take steps now to avoid learning that those already at a disadvantage suffered a greater burden both from the illness and our efforts to address it.
WHO made their decision because they worried that the increased spread of the virus needed increased action to minimize spread. School closures and travel restrictions immediately followed. And arguably, even more, needs to be done to stem the spread.
We take these steps because history teaches us that social distancing works. Although it will not alter the overall impact, it slows spread because fewer people are exposed at once. This results in fewer patients needing testing and treatment at the same time. Health providers and hospitals can then direct their attention and efforts to patients of most need. They will be less likely to run out of supplies or beds to care for patients.
As a pediatric intensive care unit (ICU) doctor in an academic medical center, I have seen the impact of efforts to contain the spread and to save resources first-hand.
Our hospital meets several times daily to review if there are enough beds in emergency rooms and ICUs, whether protective equipment like masks, gowns, and gloves are available, and to discuss potential exposures. Non-essential meetings have been canceled and remote participation has been encouraged. We take these steps because we can.
But, those most vulnerable to severe disease, will not because they cannot. People with limited mobility are unable to remove themselves from crowded living situations where the spread is more likely.
They will see the impact of this disease first, while we are still learning about its potential complications, before we have more sophisticated ways to treat it, like possible new antivirals, before there may be a vaccine to prevent more severe disease, and when our hospitals and health systems may be the most overstrained.
Those with restricted mobility include patients with chronic diseases like diabetes, cancer, asthma or COPD who require hospital admission, those with injuries or severe illness who need rehabilitation and those who cannot care for themselves who live in long-term nursing facilities.
They include those living in publicly-supported housing, which is often multi-family dwellings.
They include adults or children with behavioral and mental illnesses who live in psychiatric or residential treatment facilities.
They include children who are wards of the state due to abuse, neglect or lack of alternative placement who live in group homes. They include adult prisoners and children in juvenile detention. And, they include adults and children detained at the border and throughout the country in immigration detention centers.
These groups are similar because they cannot practice social distancing. They are also less likely to have resources for an emergency plan or to stock up on needed supplies.
Many are more likely to have lower income and be of minority race and ethnicity, who have higher rates of chronic diseases that make them more likely to have severe disease. They have a lower life expectancy, including the largest life expectancy gap in the country in my Chicago hometown.
They are more likely to be uninsured or to have public insurance like Medicaid. Hospitals that they can go to are more restricted and more likely to be overwhelmed with large numbers of early cases. If a vaccine was developed some — particularly those in prisons or detention centers — may be less likely to receive it, as they are less likely to get vaccines like the flu shot.
I am not advocating that social distancing is wrong. In fact, it is essential. Much like the idea that if everyone who can get vaccines gets them, it protects individuals who cannot get vaccines, called herd immunity, social distancing will slow the spread. It is our civic duty to do it.
But, we should take additional steps to protect the vulnerable. Institutions—particularly those at places where residents or patients cannot leave—most need remote work measures that allow non-essential workers who are able to practice social distancing to do so. This reduces resident exposure.
In health care settings, this step may also preserve staffing for individuals who may not currently be working to take care of patients but could do so in the setting of a shortage of staffing. They also need plans for essential workers who may face child-care difficulties, if their usual plans for childcare are closed, and paid sick leave with job security for sick employees to stay home.
Public health officials, researchers, and policymakers need to think about populations at greatest risk for disparities and how to protect them. They must track carefully how the virus is impacting groups with restricted mobility in particular. They should support policies to ensure early access to testing and care for these groups, including vaccination and antiviral medications, if available. And, they should think long term about how to reduce the number of people living in restricted settings.
They must also think about policies with an eye towards their risk of discrimination or hardship for vulnerable groups. Proactive programs for ensuring access to food and local shelter/daycare options for students who rely on schools to do this and emergency programs for sick leave for parents are examples of such programs that promote equity.
Undoubtedly, there will still be some unequal impact. For example, some schools will have resources to continue education online, while city or rural areas where students already have lower educational opportunities, have fewer resources and will be unable to do so. Tracking this information will help us learn if some students were negatively impacted and in planning to avoid similar situations in the future.
Like others, my son’s school is closed indefinitely. Our local library and park district canceled activities. We are socially distancing. We are privileged to be able to help #flattenthecurve. But, as a scientist who studies disparities, a lawyer who teaches public health law, and an ethicist involved in disaster planning, including addressing resource shortages, I worry about those who are not able to socially distance and not by choice. It is our duty to protect them too.
Erin Paquette is a pediatric critical care doctor, lawyer and ethicist, and assistant professor of Pediatrics at Northwestern University’s Feinberg School of Medicine. She is a Pediatric Critical Care and Trauma Scientist Development Program Scholar and co-chair of the Health Equity Task Force at Lurie Children’s Hospital.