March 11, 2020

As COVID-19 continues to spread across the United States—infecting at least 1,000 people in more than 35 states, as of Wednesday afternoon—experts are recommending that people avoid large crowds, stockpile shelf-stable foods in case they end up quarantined, and stay home from work and contact a doctor if they are ill.

But there’s a key problem with that advice: A lot of low-income people can’t afford to follow it.

Low-income jobs—line-cooks, nurse’s aids, grocery store clerks, nannies—mostly can’t be done remotely, and the majority of low-income jobs don’t offer paid sick days. Low-income people are disproportionately more likely to be uninsured or underinsured for medical care, and for many, even stocking up the pantry can be an impossible financial hurdle. According to a 2019 Federal Reserve study, 40% of Americans could not come up with $400 to cover an emergency. Lacking resources to prepare and protect against the COVID-19, many of these individuals face a higher risk of contracting—and subsequently spreading—the virus.

There’s a secondary effect, too. As states and community health departments scramble to address the COVID-19 outbreak in the U.S., they are shutting down schools, creating containment zones, and enforcing quarantines—moves that, again, often have outsized, if unintended, downstream effects on poorer people. Many low-income children rely on free and reduced school breakfasts and lunches for their daily nutrition, for example, and low-income parents can’t always afford child care when their school age kids are suddenly home all day. As schools across the nation float virtual learning in lieu of traditional classroom instruction, the millions of households that lack access to high speed internet might be out of luck.

The COVID-19 outbreak hasn’t caused these underlying problems, but it has highlighted the deficits within the U.S.’s fragile social safety net. If low-income Americans get and spread COVD-19 at a higher rate, it’s bad for everyone.

“There’s a confluence of issues that would keep individuals who are on the lower end of the income scale, or are unemployed and underinsured, from being able to stem the tide” of the virus spreading, says Mavis Nimoh, the execuitive director of the Center for Prisoner Health and Human Rights, a partnership between Rhode Island’s Miriam Hospital and Brown University’s medical school.

Elderly people are on the front lines. Not only are they are the most vulnerable to dying from COVID-19, they’re also among the poorest. They are therefore among the least able to heed the advice of the Centers for Disease Control and Prevention, and “have enough household items and groceries on hand so that you will be prepared to stay at home for a period of time.” The median income for retired adults over age 65 in 2017 was less than $20,000, according to the Pension Rights Center, a national nonprofit. Many elderly are also dependent on care from largely low-income health aides, who may themselves be disproportionately exposed to contracting the disease.

Take, for example, health care professionals’ key piece of advice: to avoid contracting COVID-19, avoid crowded areas, and more specifically, from coming within six feet of others. Many low-income families, who are more likely to live in smaller quarters and share bathrooms and kitchens with multiple people, simply can’t self-quarantine as effectively as, say, a couple living in a four-bedroom, two-bath home.

And if these health aides and other blue-collar workers do get sick, a lot of them won’t be able afford to stay home from work because, unlike many developed nations, the United States also doesn’t guarantee paid sick leave: though 90% of America’s top quartile of wage-earners have access to paid sick leave, only 47% of the bottom quarter of American workers do, according to the Economic Policy Institute. “I cannot afford to take a day off if I’m sick,” Maurilia Arellanes, a San Jose, California McDonalds employee, said in a statement demanding the fast food giant change its policies.

Limited access to healthcare is another issue that might exacerbate the spread of the virus. Even as private insurance companies, Medicare and Medicaid all vow to test symptomatic patients free of charge, 28.6 million people across the U.S. are not covered by any form of insurance at all. “There’s a lot of legitimate fear about whether they would be able to afford the services that they might need,” says Dr. Irwin Redlener, the director of the National Center for Disaster Preparedness at Columbia University. “Most people will not need much in the way of services and they should not be going to the emergency rooms, but [for] people that live their lives in constant fear of medical bills that they wouldn’t be able to handle—this is putting additional stress on them.”

Low-income individuals are less likely to have general practitioners if they come down with a fever, dry cough or shortness of breath—some of the top symptoms of COVID-19. “When we’re telling people to call their doctor and let them know if they have symptoms they might be worried about, or if they’ve had contact with somebody who may have tested positive, they may not have anybody to call,” Redlener says.

Homeless Americans are in even worse shape to deal with a deadly viral outbreak. “They’re in large group quarters, or they’re sharing other facilities like bathrooms or places like cafeterias where they eat,” says Samantha Batko, a research associate in the Metropolitan Housing and Communities Policy Center at the Urban Institute. “Or potentially, if they’re unsheltered, they’re in encampments, where they’re living in close quarters and have little access to personal hygiene facilities. There are certainly a variety of reasons for which this population is at greater risk and will likely be disproportionately affected by coronavirus.”

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America’s overcrowded prisons, where people live in close proximity to one another, also pose a challenge. Nearly 2.2 million adults were incarcerated at the end of 2016, according to a Bureau of Justice Statistics report. “They all open the same door, touch the same door and walk through the same narrow hallway, sit in the same small cafeteria, eat the same food, go back touch everything, and they all do recreation together,” explains Dr. Josiah Rich, a professor of medicine and epidemiology at Brown University. “There is not six feet between them in the building to separate people, it’s just not possible.”

Incarcerated individuals also tend to be more medically fragile than the general population, Rich adds. “If you look at the incarcerated population, on average, they appear to be about 10 years older than their chronologic age,” he says. “Somebody who’s been incarcerated for most of their life, who is age 50, has the sort of disease profile of somebody who’s at 60, and so forth. So it’s an aging population. It’s a chronically ill population.”

But if people from low-income communities are disproportionately impacted, that could be bad news for middle- and upper-income families, too. A 2018 Norwegian Work Research Institute study by researcher Svenn‐Erik Mamelund found that socioeconomic differences among individuals who contracted the 1918 Spanish Flu ended up playing a key role in survival rates. “The poor came down with influenza first, while the rich with less exposure in the first wave had the highest morbidity in the second wave,” Mamelund concluded.

In his paper, Mamelund says he’s surprised that politicians and public health officials don’t do more to take social inequalities into account when forming international preparedness plans. By ignoring these realities, he argues, everyone is worse off. In other words, failing to help low-income people prevent and treat COVID-19 might come back to hurt us all in the end.

Write to Abby Vesoulis at abby.vesoulis@time.com.

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