Commentary: Covid-19 is anything but an ‘equalizer’

Pandemics, like the 1918 influenza, have higher death rates among impoverished communities.

By Bethany L. Jones and Jonathan S. Jones / Special To The Washington Post

In a well-meaning tweet last week, New York Gov. Andrew Cuomo called the novel coronavirus “the great equalizer,” capable of sickening anyone, 20-somethings and senior citizens, ordinary Americans or famous actors. All of us could potentially contract Covid-19 in coming days and weeks, including the governor’s brother, CNN anchor Chris Cuomo, who came down with the disease last Tuesday.

Certainly, Gov. Cuomo’s broader point, that no one is immune to the coronavirus, is soberingly valid. But his phrasing is misleading.

Simply put, to call any virus a “great equalizer” is false. Pandemics amplify existing inequalities, usually hurting the poor worse than the wealthy. A century ago, history’s greatest pandemic — the 1918 Influenza outbreak — taught us as much.

No one is sure where the 1918 flu first surfaced. One possibility is U.S. Army camps in Kansas, where American doughboys fell ill in the spring of 1918. After infecting the local civilian population, troops deployed to the front lines of WWI, carrying the flu with them on steamships and trains. Soon, the virus had spread to all corners of the globe, from Philadelphia and Oslo to Canada and India.

By the time the dust settled, the 1918 influenza pandemic had killed at least 50 million people globally, far more than notoriously-bloody WWI. Some victims died when pneumonia set in. Others literally drowned as their lungs filled with fluids, according to research by Dr. Anthony Fauci (yes, that Anthony Fauci). But while mortality rates were high everywhere — around 2.5 percent globally, 20 times the rate of ordinary influenza outbreaks — the poor and the marginalized fared even worse.

In the U.S. and Europe, the urban poor died at much higher rates than the wealthy, who could afford better nursing care, the only effective remedy for influenza in 1918. In Oslo (then Kristiania), residents of one-room apartments in poor districts died at rates about 50 percent higher than those living in large apartments in wealthy neighborhoods. Wealthy residents of Kristiania’s Frogner neighborhood had the financial means and physical space to stay home, isolate themselves and rest in warm, well-ventilated apartments until flu symptoms subsided. In contrast, people living in the overcrowded, ramshackle housing of Kristiania’s impoverished Grønland-Wexels parish lacked sufficient access to food and heating, and they convalesced together in poorly ventilated rooms.

These conditions left the poor more liable to developing fatal pneumonia than the wealthy, resulting in a higher death rate in the impoverished district. In 1918 Chicago, a team of modern epidemiologists identified a similar pattern. Chicagoans living in underprivileged neighborhoods with high rates of illiteracy — an indicator of poverty — died of the 1918 flu pandemic at much higher rates than the city’s wealthy.

The inequalities of colonialism also amplified influenza’s toll in 1918. When the flu surfaced in colonial Mumbai (then Bombay), British colonizers’ complacency about Indians’ health fanned the flames of influenza in the city. Colonial officials believed in long-running stereotypes that portrayed Indians’ culture as inherently unhealthy. Predisposed by cultural biases to ignore disease outbreaks among locals, British officials refused to take seriously early reports that influenza was quickly spreading through Bombay. By the time they finally reacted, it was too late to reverse course. As a result, thousands of Indians contracted the flu as the virus ravaged the city. Unsurprisingly, Indians living in unsanitary, cramped urban housing fared much worse than the city’s European residents.

The 1918 influenza pandemic teaches us that viruses often exacerbate existing inequalities, hurting marginalized people much more than others. We’re still in the relatively early phases of the 2020 coronavirus pandemic. But, as we saw a century ago, the effects of Covid-19 will probably be much worse for the poor.

Glimmers of this inequality are already apparent at home in the U.S. and globally.

Not every American can realistically take part in social-distancing measures to flatten the curve. Smartphone location data reveals many wealthier Americans are heeding social distancing warnings and staying at home. Low-income Americans are less able to work from home, and have remained mobile out of necessity. Instacart grocery shoppers, for example, run a higher risk of contracting Covid-19 than affluent Americans who can work and shop from home, avoiding stores and crowds. Acutely aware of the risks, Instacart workers have gone on strike in some places.

Like Chicago and Oslo in 1918, residents of low-income neighborhoods in today’s New York City seem to be at an increased risk of contracting covid-19. According to newly released testing data, covid-19 tests among residents of low-income areas like the Bronx are turning out positive much more frequently than tests from wealthy neighborhoods like the Upper East Side. Data from Milwaukee also suggests covid-19 is devastating African American communities worse than other Americans.

Many countries hoping to protect citizens from Covid-19 through stay-at-home orders may be unintentionally compounding health risks for those living in poverty. In poor urban neighborhoods where residents live in proximity to neighbors, like Brazil’s favela communities, there is little opportunity for social distancing. Covid-19 could thrive in such settings. Stay-at-home orders are also impractical and even dangerous for those living in substandard housing without access to sanitary faculties or clean water.

A world map showing the running totals of those who have tested positive for the virus further highlights unequal international capacity for Covid-19 testing. More than 40 of the 50 countries having highest positive test counts fall within the top 50 GDPs in the world. This means current international tracking of positive Covid-19 cases may simply be telling us which countries are able to afford tests. Some countries, like Bolivia, are only able to test 12 people per day, creating a silence around the possible spread of Covid-19 that reflects structural inequalities in global health.

We live in an unequal world, so it’s impossible for the novel coronavirus to be an equalizing force. Like the 1918 influenza pandemic, the 2020 Covid-19 pandemic reflects and exacerbates inequalities at home in the U.S. and abroad. As government and public health officials scramble for solutions to mitigate the pandemic, they must come to grips with these inequalities so marginalized populations aren’t forced to bear the brunt of Covid-19.

Bethany L. Jones is an master of public administration fellow at the Cornell Institute for Public Affairs. Jonathan S. Jones is a historian of American medicine.

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