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Markkula Center for Applied Ethics

Public Health Justice in Pandemic Times

Homeless Man on Bike

Homeless Man on Bike

Faculty of the Public Health Program at Santa Clara University

Photo credit: Jeff Chiu, ASSOCIATED PRESS

As concern about COVID-19 spreads across the country, many of us wake up each morning and review the statistics: how many infected, how many deaths, where new clusters of infections arise. In the public health community, we have focused great effort on examining and discussing how COVID-19 is spread, and best practices for communication, prevention, testing, and treatment. 

We in the SCU Public Health program stress that understanding COVID-19 is more nuanced than adding up the total numbers of illness and death, or recognizing the etiology of the disease. We must recognize that this pandemic will hit some communities much harder than others. As COVID-19 continues to spread, we anticipate that this crisis will reveal and reinforce the existing economic, social, and racial disparities that exist in our society. COVID-19 underscores structural inequalities, and presents an opportunity for public health to enact concrete forms of justice to mitigate its impacts and protect society’s most vulnerable. 

Many professionals in higher education, the tech sector, or other parts of the business world were the first to be able to work remotely, order food and supplies online, and utilize distance technologies so that their livelihoods continue relatively uninterrupted. Universities have closed their doors. Many large technology companies have enacted work-from-home policies. These workers are encouraged to restrict non-essential travel. Through relative isolation they are shielded from the greatest risks. Jobs are protected, health insurance is at the ready, and they can weather this storm in the self-contained comfort of their homes. 

However, “social distancing” is a privilege afforded to few. These protections and luxuries are largely unavailable for people working in the restaurant and food services industries, those cleaning offices, those in the ever-growing gig economies, or the millions of people who run and work in small businesses. Hourly workers typically do not have benefits, so sick days may be uncompensated. There is simply no option to work from home at the lower rungs of the economic ladder, and in-person interactions may be unavoidable. The very nature of these occupations can put people in harm’s way, so they are exposed on the frontlines of the pandemic, cooking or delivering food, stocking shelves, taking care of kids. Social distancing is not a viable strategy for these workers. Moreover, the economic impact of COVID-19 is disproportionately affecting low-wage and hourly workers, who are the first to see reductions in hours and loss of jobs.

Still, others are extremely vulnerable, like isolated seniors, the undocumented residents of our communities, day laborers, people who are homeless, people with severe mental illness, people in jails and prisons, as well as the health and social service workers who serve these communities. These groups are at the highest risk of devastating infection and illness, but there is disproportionately little public attention paid to their situations. Those who are incarcerated or homeless, for example, typically do not have ready access to hand sanitizer, or even soap and water to help protect from disease. They are virtually defenseless against community-spread illness, and with greater underlying health conditions like diabetes and hypertension in these populations, their health consequences will be far worse.  

The COVID-19 pandemic is a textbook example of how a key concept in public health—structural vulnerability—operates in our stratified society. The most vulnerable are at greatest risk of exposure to disease and ill health, while having the fewest resources to protect them, or to fall back on for recovery. Thus, they are most likely to be harmed. Diseases arise that reinforce and deepen people’s vulnerabilities. In years past it might have been small pox, plague, influenza, or tuberculosis—now it is COVID-19. The result is an ever widening gap between the health and wellbeing of people who have resources and status, and those who do not. 

The irony is that although our society is stratified economically and socially in many ways, no one is fully isolated. When the individual picking vegetables or driving the rideshare is at risk, the risk is passed on to some degree (directly or indirectly) to those with more social and economic privileges. There are cascading health, economic, and social consequences of a COVID-19 strategy that ignores the needs of the vulnerable. The collective good throughout society is compromised by ignoring those with the greatest need.

COVID-19 and the inequalities it traces reveal society's fractures, but also present an opportunity to use the tools of public health to advocate for and with the poor. We have an ethical obligation under the health principles of justice (fair distribution of scarce resources), equity (the needs of the vulnerable merit special care) and non-maleficence (do no harm) to make sure that the most vulnerable are included in our prevention and treatment strategies. We must prioritize the needs of the vulnerable—and those who work closest with them—through allocation of healthcare resources, prioritized testing, and other forms of economic and social support to prevent and tackle the spread of COVID-19. This is not only an issue of ethics, or a question of what we “should” do. It’s a matter of what needs to be done. The history of public health has repeatedly shown that we cannot end outbreaks and improve the health of communities if the conditions and needs of the impoverished and marginalized are not attended to. Our actions in pursuit of these justice principles have the potential to not only help overcome this stressful period, but also strengthen and make our whole community more resilient for the longer term.

Faculty of the Public Health Program at Santa Clara University:

Jamie Suki Chang PhD, MA

H. Westley Clark MD JD MPH

Frederick J. Ferrer MS

Sarah MacGregor, MA MPH

Sonja Mackenzie DrPH, MS

Hoda Abdel Magid PhD

Veronica Miranda, PhD

Michele Parker PhD

Tracy Ruscetti, PhD

Katherine Saxton PhD

Craig Stephens PhD

Sheila Yuter, EdD


Mar 13, 2020

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