Sean A. Valles
[This is an advance copy of an article that will appear in print in September 2020 as part of the KIEJ’s special double issue on Ethics, Pandemics, and COVID-19.]
ABSTRACT. The COVID-19 pandemic in the US has inspired conversations about which features of the pandemic’s impacts were(n’t) unexpected, as well as why and how. Looming in the background of these discussions are political questions about the blameworthiness of particular institutions and leaders therein, and what COVID-19 disasters within US institutions mean for future discussions about how to reform those institutions. This paper will argue that the inequitable harms of the COVID-19 pandemic in four especially hard-hit US institutions—jails and prisons, meat processing plants, hospitals, and eldercare facilities—were: (1) not so unpredictable as claimed by some commentators, (2) traceable to institutional flaws known prior to the pandemic, and (3) can be fruitfully understood through the lens of “fundamental cause theory,” which offers a model for why and how social resources and deprivations create predictable patterns of harms from health hazards, even when the hazards are new.
INTRODUCTION: HEALTH THEORY AND THE POLITICS OF ‘UNFORSEEABLE’ PROBLEMS
“Nobody had ever seen anything like this before.”
(Donald Trump, March 19, 2020)
“Nobody would have ever thought a thing like this could have happened.” (Donald Trump, March 26, 2020)
There is a lot at stake in the current and forthcoming debates over what/why/how the COVID-19 pandemic’s effects on the US were unpredictable. These debates are crucial to both our assessments of backward-looking culpability (who should have known or acted better, and when?) and in the related but even more socially important task of guiding decisions about how to rebuild society after the pandemic subsides. The more we treat the harm as unexpected—a fluke—the more we bolster the argument that no major structural changes need to be made to the US health system. I come to this question as one of the scholars who has been participating in the vibrant multidisciplinary study of the ways that the US health system is abysmally ill-designed, as well as the study of the ways that this undermines health equity in the US. The presence of some kinds of uncertainty, including the uncertainties surrounding the biological nuances of a newly uncovered pathogen, does not entail that most of the pandemic’s health system failures were unpredictable, nor that it would be largely unpredictable which populations would bear the brunt of the harms of those failures. We already knew rather a lot about what is broken in the US health system—including its weaknesses during a potential pandemic—and fundamental cause theory provides a theoretically developed and empirically testable means of predicting which populations will suffer from health system failures and understanding why past suffering happened (Link and Phelan 1995).
Jails and prisons, meat processing facilities, hospitals, and eldercare facilities have all been hit especially hard by the US pandemic. These four institutions are also important pieces of the US health system. By “health system,” I mean the total set of components of a society that play significant roles in the shaping of the population’s health; this includes the healthcare system, but also includes the food system, social welfare safety nets, the designs of the spaces where people live/work/play, labor conditions, and so on (Valles 2018). This paper will examine the suffering of the people in those four institutions with the goal of illustrating how those patterns of harm are consistent both with what we know about the patterns of health inequities, and also with the deep institutional flaws pointed out in these institutions before the pandemic. The COVID-19 pandemic did not suddenly take well-functioning US health system institutions and turn them upside down. Rather, these institutions were already broken before COVID-19 arrived: inequitable, unsustainable, and detrimental to public health. The unethical harms of the COVID-19 inequities can be better understood by understanding them in light of the existing patterns of inequities.
THE LIMITS OF UNCERTAINTY
Rhetoric around COVID-19 has relentlessly emphasized uncertainty, debates among experts, and the uniqueness or novelty of the COVID-19 pandemic. For instance, philosophers of science Winsberg and Schliesser contrast “mature” climate science to the science of COVID-19:
Ultimately, what is needed is more and not less critical discussion of the science and politics behind our response to the coronavirus. “Trust the science” is a better slogan when the science, like climate science, is mature, multi-disciplinary, and has been subjected to intense scrutiny. (Schliesser and Winsberg 2020)
Here, the science surrounding COVID-19 is framed as relatively untrustworthy by virtue of its being immature and unvetted. I agree that trust must be earned. But it is a mischaracterization of epidemiology and other population health sciences to cast the relevant science of the COVID-19 pandemic as generally immature. Though the COVID-19 strain is new, the underlying public health sciences are mature and quite multidisciplinary (Keyes and Galea 2016; Valles 2018; Rosen 1993). It is easy to elide uncertainty about the underlying science of COVID-19 research in general with uncertainty about the details of how this coronavirus differs from other coronaviruses we know better, and uncertainty about how to effectively use, evaluate, and refine “non-pharmaceutical interventions” for COVID-19—e.g., the principles of social distancing that have been implemented in diverse ways in diverse settings around the world in 2020. Biology does not get rewritten when a new species evolves; ecology does not get rewritten when the new species begins interacting with existing species.
The fact that many global populations are implementing distinct and ever-evolving versions of these social distancing interventions also means that it will be very hard to interpret or to draw generalizable conclusions from the pandemic data collected. Of course, we have been unable to pinpoint all of the crucial epidemiological and pathological features of a disease studied for only a few months, while we simultaneously watch and interfere with a pandemic afflicting diverse bodies, communities, and places. Yet, rhetorically, when public discourse fixates on these uncertainties it serves to downplay the useful and well-vetted knowledge we do have at our disposal for understanding and responding to COVID-19.
Over two decades ago, Bhopal (1997) scrutinized the similarities and differences between twenty-five different epidemiology textbooks published since 1980, showing how different emphases, prioritizations, and methodological disputes created pedagogical diversity among works that are rooted in shared basic scientific ideas. For instance, Bhopal notes that texts disagree on the epistemic grounding of “case-control studies,” which make inferences about disease features by comparing a population with a disease against a control group of people who do not have the disease but who are otherwise similar to the first population (Bhopal 1997). This has remained philosophically and methodologically contentious (Broadbent 2013, 21–22), which in turn affects how we interpret and use COVID-19 case-control evidence, such as the evidence suggesting that gastrointestinal symptoms are a useful predictor of being infected and also of having a more gradual and less severe course of disease (Nobel et al. 2020). Uncertainty and ignorance are socially contingent (on the epistemic frameworks adopted by communities), socially constructed (by how we do/don’t interact with the world and with existing knowledge), and deeply political (Tuana 2004; Proctor and Schiebinger 2008).
Prior to the pandemic, Wucker coined the term “gray rhino”—a predictable but ignored problem—as a rebuttal to the inappropriate overuse of the notion of “black swan” problems (problems that are truly unlikely or hard to imagine). For instance, the 2008 financial crash had been preceded by a series of warnings from policymakers, journalists, etc. (Wucker 2020). Wucker explains that COVID-19 is also such a gray rhino, despite efforts to explicitly explain it away as black swan problem; efforts that, by strong implication, absolve those who failed to effectively prevent or respond to it. For instance, it must not be forgotten during current US debates over the feasibility of COVID-19 mass testing and contact-tracing that the May 2019 cover article for the American Journal of Public Health was “Public Health Workforce: Threatened by Mass Extinction?”
The rhetoric around COVID-19 being especially enigmatic and unpredictable are most acutely in tension with the fact that, in some concrete ways, the COVID-19 pandemic was not just predictable, it was predicted. Just months before COVID-19 appeared, the Department of Health and Human Services completed a simulation scenario of a new influenza strain appearing in China and then spreading to the US, killing 586,000 out of 110 million people infected (Sanger et al. 2020). Moreover, the COVID-19 virus, SARS-CoV-2, is closely related to two other viruses that happen to have garnered international attention as potential sources of global pandemics just within the last 20 years: SARS-CoV-1 (responsible for the 2003 SARS epidemic) and MERS-CoV (responsible for the 2012 Middle East respiratory syndrome epidemic) (Coronaviridae Study Group of the International Committee on Taxonomy of Viruses 2020). Four other coronaviruses have long been endemic in human populations and are common causes of respiratory infections (Corman et al. 2018).
There is an extensive health science literature on how various pieces of the US health system are clearly broken, or are so brittle that the shock of a new crisis would make that piece shatter (a good overview of the literature appears in: Woolf and Aron 2013). To extend Jones et al.’s cliff analogy for health equity, some new agent (i.e., COVID-19) could unexpectedly begin pushing people toward the edge of a cliff, and as it is happening, the agent may remain mysterious in many ways (Jones et al. 2009). But we already know a lot about the empirical and ethical problems surrounding which populations live nearest to the edge of the cliff, which populations will be protected by fences before they fall, which ones will be quickly met by ambulances after they fall, and which ones will get better care once they reach the hospital after a fall (ibid.). Such is the US health system: the protection of fences, distance from the edge of the cliff, and the speed/efficacy of the care that one receives after falling are all luxuries available on the basis of well-studied and disturbingly inequitable criteria.
FUNDAMENTAL CAUSE THEORY
My previous work has urged philosophy of epidemiology to take up fundamental cause theory as a lens for critically evaluating patterns of causation in unjust societies (Valles 2019). Looking through the lens of fundamental cause theory guides one to focus on the way that certain social resources serve as flexible buffers against the world’s hugely variable and constantly-evolving set of hazards (drought and famine one year; flooding and cholera the next) (Link and Phelan 1995). The three criteria that make a cause a “fundamental cause” are the following:
First, a fundamental social cause influences multiple disease outcomes through multiple risk factors among a substantial number of people. Second, a fundamental social cause involves access to resources—knowledge, money, power, prestige, and beneficial social connections—that can be used to avoid risks or minimize the consequences of disease once it occurs. Third, fundamental social causes are robustly related to health inequities across time and place. These enduring relationships occur because the association between the fundamental cause and health is reproduced over time via the creation of new intervening mechanisms. (Hatzenbuehler, Phelan, and Link 2013)
The fundamental causes: prestige, money, education, racial privilege, freedom from stigma, and a disputed/growing list of other social resources all allow one to evade harms of many different types (Valles 2019; Hatzenbuehler, Phelan, and Link 2013; Phelan and Link 2015). Consistent with the above criteria, individual fundamental causes can be delineated as either the presence of a benefit of the absence of a detriment. This gives a sort of ambidextrousness, in that, for example, the same fundamental cause can be characterized as ‘stigma’ or as ‘freedom from stigma.’ As explained next, since I find it easier to conceptualize fundamental causes as buffers or metaphorical armor, this paper reflects my preference for the positive versions: ‘freedom from stigma,’ etc.
Each fundamental cause individually (or in combination with others) serves as a sort of armor against a range of different types of health harms. Fundamental cause theory, in a sense, identifies patterns of protection and harm that hold remarkably stable across time and across different population contexts. The mechanisms by which money, prestige, etc., are helpful for one’s health vary enormously—a key piece of the theory—and those mechanisms can be quite unexpected (who knew that paid grocery delivery services and telework options would be such widely coveted health-protecting resources in 2020?)—but it remains stable that money, prestige, etc., remain helpful across time and geography (Valles 2019; Link and Phelan 1995). Money can’t help you buy your way out of a randomly-striking untreatable cancer, but if a hazard is preventable or treatable, then money almost certainly helps buy relative safety.
Looking at the case of COVID-19, Whitney Laster Pirtle has argued that “racial capitalism” should be recognized as a fundamental cause in its own right, and that it has operated as a devastating fundamental cause of COVID-19 harms in Detroit. Racial capitalism protects some people and leaves others unprotected. Laster Pirtle writes the following:
Racism and capitalism mutually construct harmful social conditions that fundamentally shape COVID-19 disease inequities because they (a) shape multiple diseases that interact with COVID-19 to influence poor health outcomes; (b) affect disease outcomes through increasing multiple risk factors for poor, people of color, including racial residential segregation, homelessness, and medical bias; (c) shape access to flexible resources, such as medical knowledge and freedom, which can be used to minimize both risks and the consequences of disease; and (d) replicate historical patterns of inequities within pandemics, despite newer intervening mechanisms thought to ameliorate health consequences. (2020, 1)
These sorts of harms should not be too surprising to those familiar with the history of Detroit, and that is the point. The vulnerabilities faced by (predominantly low-income and Black) Detroiters are the result of explicit and implicit social policies, resulting in the population’s segregation, poverty, etc.
Fundamental cause theory helps perform a critical ethical analysis of the ongoing COVID-19 pandemic’s burden on the US. It cautions us to resist the impulse to infer that novel hazards (COVID-19) must therefore cause novel and unpredictable patterns of harm. Knowledge about the ways that socially-created vulnerability operates means that we can—and ethically must—prepare for unknown new hazards by scrutinizing and reforming the conditions that make people vulnerable to whichever hazard appears next. For instance, here is a prediction I published in 2018, based on fundamental cause theory:
It is a matter of historical inevitability that new infectious diseases will sporadically emerge, and the world will soon contend with the next SARS, MERS, strain of influenza, etc. When some groundbreaking new medication arrives, it will first benefit those with more status and resources—those who have the benefit of flexible social buffers such as prestige, money, racial privilege, and an absence of stigma against them. (Valles 2018, 122)
Interestingly, the SARS-CoV-2 virus’s closest relatives are the quoted SARS and MERS. And in one sense the prediction of medication benefits being inequitable remains to be tested since there are no clearly very effective new medications for COVID-19 available. As of writing, the current most promising experimental drug available, remdesivir, has only begun getting very limited distribution to hospitals in the US. Though, after the early days of distributing this scarce and coveted resource, the allocation of the resource appeared so misaligned with equity that the Infectious Diseases Society of America and the HIV Medicine Association wrote a joint letter to the White House coronavirus task force pleading for it to distribute remdesivir in a more transparent and equitable way (File and Feinberg 2020).
So far, the aforementioned ‘non-pharmaceutical interventions’ (stay-at-home orders with exceptions for essential workers, business closures, etc.) are the main tools used in the absence of highly effective treatments or vaccinations (Jones et al. 2009). These policies are novel formalizations of the ancient practice of reducing social contact during an epidemic, designed and refined to suit the needs of individual jurisdictions (whether effectively or not). These health-promotion interventions have already been bearing out those predicted patterns of which populations would be most harmed, based on fundamental cause theory.
As will be illustrated in the upcoming examinations of four US institutions whose socially marginalized members bore especially heavy burdens of COVID-19, fundamental cause theory provides a way of seeing commonalities and patterns across a diverse range of COVID-19 inequities. Often these harms will converge, such that multiple fundamental cause vulnerabilities afflict a single population, including low-income immigrants of color. This issue of converging socially-imposed vulnerabilities is a well-known problem and has been variously described and theorized—e.g., “a cascade of deprivations greater in their magnitude than each would have been in isolation” (Powers and Faden 2006, 30; also see footnote 1).
Fundamental causes serve as an organizing schema for health equity and the operation of the much-cited ‘social determinants of health.’ It addresses a vagueness in the notion of social determinants of health by looking at a layer of causal influence overlaying the patterns of social determinants—the causes hiding behind the causes—that Jones et al. conceptualize as the “social determinants of equity” (Jones et al. 2009). That is, fundamental cause theory guides us as we trace the connections between the local harms to marginalized social groups (e.g., infections and deaths among prisoners, who are disproportionately Black) through the social determinants/conditions that harm them (e.g., unsanitary prison living conditions) and a step further to the factors that differentially expose people to such social determinants (e.g., racism), and explains that the intervening mechanisms will vary and shift (e.g., policing and prosecution processes differ and evolve, but racism remains a constant background condition).
JAILS AND PRISONS
It is not an accident that two of the worst COVID-19 micro hot spots in the US are jails: New York’s Rikers Island and Chicago’s Cook County Jail emerged as COVID-19 infection hot spots within city hot spots (Lopez 2020). It is not a surprise that they and other jails and prisons have been hit hard, nor is it a surprise that the harms are spilling over into their surrounding communities. As Wanda Bertram of the Prison Policy Initiative explains, COVID-19’s pattern of harms is just a particularly glaring example of a familiar pattern:
It’s an exaggerated version of what we talk about all the time when we talk about the public health impact of mass incarceration—when we say that this is not just something that puts incarcerated people in danger but something that puts whole communities in danger. (Lopez 2020)
Mass incarceration has been a growing area of study in population health research (see, for example, the themed issues on the topic in the August 2018 and Supplement 1, 2020 issues of the American Journal of Public Health). In an attempt to quantify the net mortality harms of incarceration on the poorest 25% of the US population, Nosrati et al. used cross-state comparison data to estimate that “each additional prisoner per 1,000 residents (mean = 4.0, s.d. = 1.5) is associated with a loss of 0.468 years [of life expectancy at age 40]” (2018, 720). For reference, the US incarceration rate is roughly7 per 1,000 residents, while almost all peer high-income countries’ rates are under 2 per 1,000 residents (Wagner and Sawyer 2018).
The burdens of incarceration are anti-poor, and racist via clear disproportionate impacts—e.g., 40% of prisoners are Black despite only 13% of the US being Black (Sawyer and Wagner 2020). According to a Robert Wood Johnson Foundation report, one conceptual model of mass incarceration’s harms on public health is that it generates a vicious cycle of harmful phenomena that feed into one another: “Racism and/or lack of economic opportunity”—notably, these are both fundamental causes—leads to discriminatory policing/arrests/prosecution/sentencing, which in turn leads into a web of intertwined outcomes: “incarceration,” “desperate poverty; powerlessness; homelessness,” “worse physical and mental health,” and “social exclusion and marginalization; inability to earn income, obtain housing, or vote” (Acker et al. 2019, 10). In other words, mass incarceration offers a number of ways in which it contributes to the harms of three fundamental cause inequities in particular: it preys on those who lack the fundamental cause protections of money and racial privilege, and it also contributes its own variety of stigma to the world (stigma against those with criminal records).
Tschaepe has shown how US mass incarceration creates an ethical vicious cycle, akin to the way that it creates a vicious cycle of health harms. US society, in part intentionally, places prisoners into institutions with a vile winking expectation that part of the punishment is that they will be sexually abused inside a crucible of toxic masculinity. This gravely unethically harms prisoners, and then goes on to harm communities because toxic masculinity only gets further ingrained in culture, thus reinforcing the cycle of violence (Tschaepe 2015). Drawing on experiences doing work in prisons, McHugh notes that incarceration creates a number of epistemic injustices related to health, including the ways that the institution manipulates prisoners into losing a sense of agency, which is a psychological harm generally but also sabotages prisoners’ abilities to advocate for their healthcare needs while incarcerated (McHugh 2018).
While there have been piecemeal efforts to reform sentencing laws and other such modest reforms to the criminal justice system, the mass incarceration problem’s structure makes a piecemeal dismantling implausible. In reviewing the problem of mass incarceration as a driver of health inequity, Wilderman and Wang caution the following:
Were the USA to return to the levels of incarceration of the 1970s, at least a half a million people employed by the criminal justice system could lose their jobs, and 63 million individuals would still have criminal records. The criminal justice system is so deeply rooted in America’s political system and socioeconomic structures that the damage to the health of our communities cannot be mitigated without addressing the root causes of mass incarceration and the forces that inevitably seek to maintain it. (2017, 1472)
The advice here is similar to the recurring advice in fundamental cause theory, social determinants of health research, population health science research, and social justice scholarship of many sorts: the harms resulting from social injustices must—sooner or later—be addressed at the roots (Link and Phelan 1995). The US mass incarceration system is unethical all the way to its core, and there is no viable alternative other than its replacement (see arguments for prison abolitionism in: Davis 2003). This is not to claim that suitable institutional replacement(s) will be easy to identify and implement, nor that the process will magically stop the ripple effects of past harms, as Wilderman and Wang explain. But mass incarceration will remain a thorn in the side of US public health so long as it exists, whether or not there is a pandemic exacerbating and drawing attention to this institution.
MEAT PROCESSING PLANTS
Meat processing plants, like prisons, sit at the intersection of multiple kinds of avoidable injustices, preying upon those who lack the benefits of protection from fundamental causes of prestige, money, and racial privilege. Meat processing plant workers are predominantly people of color, approximately one third are undocumented immigrants, and the pay is low (Cain 2018). After meat processing plants began disruptions and closures due to COVID-19 outbreaks, the chairman of Tyson Foods declared in simultaneous full-page advertisements in multiple newspapers, “Tyson Foods places team member safety as our top priority” and “The food supply chain is breaking” (Tyson 2020). This rhetoric obscures the well-documented fact that Tyson Foods and the wider industry have vehemently fought against efforts to protect worker safety and well-being, contributing to meat processing plant work being among the most dangerous work in the US (Lowe 2017; Stuesse 2016). The fast pace of the factory line and repetitive work has led to widespread repetitive motion injuries and carpal tunnel syndrome, accompanied by less common but far more severe injuries, including amputations of fingers/limbs and deaths (Gerlock 2016). Under-reporting by (rightfully) fearful employees and the use of outside contractors make the problems even more dire than what official records report (Gerlock 2016). Trump responded to the added harms of COVID-19 infections by explicitly seeking to prevent plants with severe COVID-19 outbreaks from shutting down, declaring them part of “critical infrastructure” via the Defense Production Act (Telford, Kindy, and Bogage 2020).
Trump has infamously made it a centerpiece of his presidency to loudly decry the very presence of undocumented immigrants, and hurl racist accusations against them—the same people whom he has now deemed critical to the US and commanded to return to unsafe working conditions. All the while, it is disturbing to consider that workers in raw food processing facilities work in such unsanitary conditions that they cannot help but spread a viral disease amongst each other. In 1906, Upton Sinclair’s The Jungle famously sought to bring public attention to the plight of immigrant meat processors, remarkably succeeding in inspiring the US public to successfully demand sanitary reforms in the industry, but not labor or immigrant civil rights reforms (see discussion of the historical context in: Pacyga 2015).
The US meat mass production system’s strongest defense co-opts the aforementioned critiques that it is unethical, including harmful to its impoverished workers, by touting its ability to “feed the nation” with “affordable” food (Tyson 2020). To scholars of industrial agriculture, such claims ring false. The meat produced by this system is inexpensive in the same narrow sense that coal energy is relatively cheap: both industries offer lower price tags in the marketplace by passing on the costs of its harms to others in society and concealing the ethical costs. Garner and Rossi summarize the ethical problems of the industrialized animal farming system this way:
Significant evidence supports the conclusions that industrial farm-animal production is highly detrimental to animal welfare; contributes substantially to anthropogenic greenhouse gas emissions, environmental pollution, and the risk of zoonotic disease; lowers the quality of life in rural communities; lowers the overall amount of food available as compared to alternative agricultural systems; and promotes a diet rich in animal products that is detrimental to the public’s health. (2014, 1232)
These problems are preventable. And even the rebuttals—e.g., that it provides cheap food the population—rest on the concealing of the full costs (Garner and Rossi 2014), since government farming subsidies and pollution regulations serve industry interests.
Strategically placing factories in locales with limited protections for collective bargaining and unions, meat processors have proceeded to recruit Latino/a/x workers, especially immigrants, cultivating and leveraging the fundamental cause vulnerabilities of the workers—lack of social prestige, lack of racial privilege, and lack of money—to maximize profits (Stuesse 2016). As Stuesse (2016) examines in ethnographic work on poultry processors in the US South, the fact that these jobs has previously been largely held by Black workers created complex new challenges in building sufficient worker solidarity to push back against the exploitive working conditions. This aligns with the public health research on unions, which has highlighted the wide range of benefits to the wellbeing of workers and their communities due to facilitating better living conditions, increased community engagement, etc. Wright (2016) summarizes, “the decline of American unions is a threat to public health,” in a an article that highlights some union benefits that have received renewed US public interest during the COVID-19 pandemic: safer working conditions, paid leave, living wages, stable health insurance, and in the specific case of nurses unions: better care for patients.
Meat processing plant workers’ suffering is one set of examples of how fundamental cause vulnerabilities combine in complex ways (see footnote 1). The burdens placed on immigrants are especially illustrative here, and not just the impoverished and racially ‘othered’ immigrants working in meat processing plants. One of the biggest obstacles to US resilience to the next health crisis—whatever it may be—is that a huge segment of the US lives on the edge of financial disaster every day. Only 61% of US households could afford to pay a hypothetical new $400 expense without borrowing money to pay it, with Black and Hispanic families having far less ability to pay. In the US fundamental cause context, immigrants suffer from low prestige and often also from lack of racial privilege, so it is unsurprising that federal too-little-too-late economic relief cash distributions (~$1,200 per eligible adult) barred non-citizens from receiving the funds, and even barred the citizen spouses of non-citizens, further harming the households of immigrants. Even the nuances of a new financial assistance program can follow predictable fundamental cause patterns by managing to find a novel way of remaining out of reach for people lacking fundamental cause protections.
HOSPITAL HEALTHCARE WORKERS
Healthcare workers in hospitals have suffered a disproportionate number of COVID-19 infections (Bellisle 2020). Intuitions about whether this is an ethically troubling inequity might go in either of two directions: either it’s a more-or-less necessary occupational hazard during a pandemic, or it’s troubling that healthcare workers are not being adequately protected against a virus that is primarily spread by contact with droplets of body fluids. In the analysis offered here, hospital healthcare workers make for a complicated case for examining via fundamental cause theory, health inequity and vulnerability. Some hazards faced by clinicians are regrettable but not necessarily inequitable—e.g., care work requires a certain amount of emotional burden that it is inextricable from the activity of caring (Forster 2009). Where it gets counterintuitive is that the best-known hospital caregiving professions—physicians and registered nurses—tend to make middle-class wages and have relatively high social prestige (e.g., nurses have long topped the list of professions most trusted to be honest and ethical, and doctors are near the top too [Reinhart 2020]), all while working within a moneyed institution. This would intuitively put workers in good shape entering into health crisis. After all, even if an infectious disease brings new risks to hospital workers, these sorts of workplace hazards are foreseeable in a hospital, and hospitals typically have financial resources available for adjusting to new conditions.
Despite those seemingly positive background conditions, COVID-19 has inequitably harmed a subset of hospital workers due to two vulnerabilities built into the ill-designed US healthcare system. First, despite being moneyed institutions, there is enormous economic inequity among hospital healthcare workers, combining in part with racial inequity. Despite the typically middle-class wages of nurses and upper-class salaries of physicians, many other healthcare workers are paid poverty wages. Second, COVID-19 gives a poignant new illustration of the bizarrely tragic phenomenon long discussed in by health policy scholars—the US healthcare system squanders its ample resources via a convoluted system that is organized around building viable businesses more than it is organized around benefitting patients.
An analysis of wages among female healthcare workers yields a disturbing picture of the intersections of racism, sexism, and economic exploitation in healthcare: “Of female health care workers, 34.9% … earned less than $15 per hour. Nearly half of Black and Latina female health care workers earned less than $15 per hour, and more than 10% lacked health insurance” (Himmelstein and Venkataramani 2019, 198). These imposed economic vulnerabilities and healthcare access vulnerabilities (an outrageous problem to have among healthcare workers)—are themselves rooted in racism and sexism (in part manifesting as low prestige inside a sexist institution), combined with lower occupational prestige—have resulted in higher COVID-19 burdens among female healthcare workers and among Black healthcare workers.
Based on preliminary data, Black healthcare workers seem to have been greatly disproportionately burdened by COVID-19. Only 11.6% of the healthcare workforce is Black (just below being representative of the US overall) (National Center for Health Workforce Analysis 2017), but early CDC data indicate that 21% of the healthcare workers who have contracted COVID-19 are Black (CDC COVID-19 Response Team 2020). Meanwhile, women (doing a disproportionate amount of undesirable work in the hierarchical and sexist medical system in which gender and prestige are tied) make up 73% of healthcare workers who contracted COVID-19 (CDC COVID-19 Response Team 2020). Again, those who lack the social protections of fundamental causes predictably face disproportionate harms from health hazards. This brings us to the related second reason that the intuitive affordances of working in healthcare somehow did not protect healthcare workers from harms: the precarity of socially marginalized healthcare workers rests atop the bizarre and precarious US healthcare system.
The US spends far more per capita on healthcare than peer nations—double the average of peer nations (Sawyer and Cox 2018). The US healthcare system is only gradually crawling away from a fee-for-service model, under which hospital revenue generally flows based on the services provided and what health care insurers are willing to pay for those services. Hospitals make money by having a financially viable portfolio of services provided to patients covered by insurers who pay favorable rates for those treatments. The results can be odd, such as that pediatricians (on average) make less than half the salary of plastic surgeons, and the only specialty making even less than pediatrics is … “public health and preventive medicine” (Kane 2019). Helping patients is sometimes profitable. But, as Burke and Ryan put it, the ethical problem is that “costs are not strongly related to quality in the United States” (2014, 125).
The result of this bizarre financial model is that hospitals have struggled in counterintuitive ways during the COVID-19 pandemic. The US federal government, state governments, and individual healthcare facilities entered into a perverse bidding war over personal protective equipment such as masks since each of the entities is a business in a free market. At the same time, there was a sudden decline in patients seeking elective treatments. These elective treatments are the profit base of most hospitals and clinics. The result is that during a time of desperate healthcare shortages, many hospital workers have been laid off or furloughed (Derysh 2020). Not only are US hospitals not built to accommodate public health emergencies, they bizarrely are struggling to pay their bills and adequately equip their staff with basic protection gear just as society most relies on these institutions (Dixon, Erb, and Shamus 2020). And, when hospital financial models suffer, their employees with existing vulnerabilities are the ones that most suffer from loss of wages or continued work in dangerous conditions (due to lack of sufficient protective equipment, etc.).
As of early May 2020, about a third of all US COVID-19 deaths have been among eldercare facilities’ residents or caregivers (Yourish et al. 2020). While it has been widely discussed that COVID-19 risk is far higher among elders, this does not mean this terrible burden of mortality in eldercare facilities was unavoidable. Rather, it reflects the same pattern discussed throughout this paper: available evidence that such harms could foreseeably happen in an institution, the institution being fundamentally flawed and ill equipped to prevent or adapt to the crisis, and fundamental cause theory giving the grim prediction that the burdened populations will continue being at risk from future crisis until we reform the societal conditions that motivated the creation of this flawed institution.
It is important context that eldercare facilities such as nursing homes have long known about the dangers of infectious disease, with seasonal flu being a particularly deadly recurring threat.
Long-term care facility environments and the vulnerability of their residents provide a setting conducive to the rapid spread of influenza virus and other respiratory pathogens. Infections may be introduced by staff, visitors or new or transferred residents, and outbreaks of influenza in such settings can have devastating consequences for individuals, as well as placing extra strain on health services. (Lansbury, Brown, and Nguyen‐Van‐Tam 2017, 356)
In other words, eldercare facilities ought to be well prepared for controlling COVID-19 since effective physical resources, training, and protocols are things that responsible eldercare facilities ought to have in place in preparation for seasonal flu and other respiratory infections.
Many eldercare facilities tragically failed to effectively protect staff and residents. Seeking to avoid accountability, leaders of long-term eldercare facilities are now seeking exemption from lawsuits resulting from the deaths of their residents. Despite the fact that these needs have been predicted and described in detail as basic infection control standards for facilities that face annual threats from flu season, the (predominantly for-profit) long-term care industry is selling a different story: “Now the industry is forging ahead with a campaign to get other states on board with a simple argument: This was an unprecedented crisis and nursing homes should not be liable for events beyond their control, such as shortages of protective equipment” (Condon, Mustian, and Peltz 2020).
“Direct care workers” do some of the most undesirable and low-paying work in healthcare, helping people with bathing, using the bathroom, assisting with everyday tasks, and a variety of other jobs, all for minimum wage or little more. Such jobs in nursing homes have a relatively low bar for minimum training and “because pay rates are low and many jobs are part-time, nearly half of direct care workers are eligible for public assistance” (Institute of Medicine 2015, 249). And, in keeping with the previously discussed racist and sexist patterns in healthcare personnel wages and status more generally, “about 90 percent are women, and 45 percent are African American or Hispanic” (Institute of Medicine 2015, 249). These problems are also not relegated to nursing homes and other long-term eldercare facilities. The chief alternative to institutional care—home care—brings lower risk of COVID-19 due to the lack of high-density housing of high-risk people, but does not solve the root ethical problems of societal devaluing and neglect.
The low wages of home care workers are rooted in the history of exploitation of labor based on race and gender, particularly the devaluation of women’s labor in the household. Because women often do this work for their families for “free,” it isn’t considered deserving of the same respect—and wages—offered to workers who are employed outside the home. Thus, the women—and, in particular, women of color—who do this work have long suffered from substandard wages. Of home care workers, 89 percent are women, and more than half are people of color. One in four home care aides is an immigrant to the US. (Paraprofessional Healthcare Institute 2015, 9)
Once again, racism, economic exploitation, and exploitation of women and immigrants’ low prestige lay beneath the observed problems.
In one sense, the eldercare crisis manifests a failure of societal design emerging from a devaluing of elders. Many US elders must choose between ‘aging in place’ (remaining in one’s home, perhaps with assistance of some sort) in houses/neighborhoods that tend to be ill-equipped for elders’ lives, or moving into eldercare facilities that vary enormously in quality, partly depending on cost. This is a serious ethical problem (Molinsky and Forsyth 2018). The proximate problem of COVID-19 devastating some eldercare facilities links up with much deeper fundamental cause root problems—racism and a social prestige (in a system that devalues the work of women of immigrants). These root causes manifest in the mid-level social problem of US society’s collective unwillingness to engage with the problem of elder care being a resource-intensive enterprise. In the absence of good solutions or even much collective discussion at all, precarious elders are kept out of sight and out of mind, tended to by members of society who are themselves devalued. An ethical society must foster the wellbeing of elders, a goal that depends on building flexibility into their surroundings, “from caregiving to medical care to accessible housing and transportation to a supportive cultural milieu” (Reynolds 2018, S35).
HOPE AND SOLIDARITY
There is a certain bleakness to looking at the US COVID-19 impacts through the lens of fundamental cause theory and the previous literature on the crumbling US health system. Yet I think there is room for optimism in the ways some temporary COVID-19 responses are cracking open the window of possibility for long-term change. For instance, many jurisdictions have been releasing some prisoners from overcrowded facilities, on the rationale that they are not community threats due to age, ill health, or behavior while incarcerated. This gives a new lens on the existing ethical prison reform/abolition debate, which has been asking why we would continue to incarcerate these and many/all other prisoners during non-emergency times. Similar ethical cases apply to other temporary measures that have been offered as ethical means of managing the temporary pandemic crisis: robust unemployment insurance, forbidding landlords from evicting tenants, flexible mortgage forbearance policies, even universal basic income.
What would it look like to build a society that fosters health in an ethical way, a society that is more resilient to the shifting landscape of health threats? Returning to fundamental cause theory, the advice is: “if one genuinely wants to alter the effects of a fundamental cause, one must address the fundamental cause itself” (Link and Phelan 1995, 88). Prisons and eldercare facilities will continue to be loci of health crises (who knows what crisis will come next?) until such time as they cease being places where we willfully hide away people we collectively choose to not value as a society (elders and their caregivers alike). So long as we allow some socially essential occupations—such as healthcare workers—to be paid poverty wages and given unreliably safe working conditions then we will continue to see them take the brunt of health harms. So long as we allow meat processing companies to exploit migrant workers (who typically lack the social protections of prestige and of racial privilege) and cause incalculable non-human animal suffering—and with no accountability for the hidden costs of the enterprise such as carbon emissions—then we will continue to see horrors all too similar to the ones Upton Sinclair decried in 1906. Solidarity does not follow automatically from being confronted with the suffering of our neighbors. But, bioethicists have indeed made a compelling case for solidarity being essential for the goal of building a world in which equitable health can exist (Sherwin and Stockdale 2017; Jennings 2015; Prainsack and Buyx 2012).
Now that the cracks in the foundations of these four US health institutions (and others) have opened more widely, it creates an opportunity to create something better. Those previously cited calls for solidarity are quite complementary to the calls for a complete “culture of health”—the de facto motto of “population health” advocates (Valles 2018), as popularized by the Robert Wood Johnson Foundation. The US’s health problems are as deep-seated as culture is, and as widespread as culture is. For instance, there is a US social value of “self-reliance” (Woolf and Aron 2013, 223–24), manifesting in contexts such as the protests against COVID-19 lockdowns and the rejection of the advice to use a mask in order to protect possibly unknowingly-infected people from harming others. This stands in stark opposition to a social value of “shared responsibility,” which would be more conducive to community health, and this difference seems to be contributing to the US having worse health than peer nations (ibid.).
Foundational population health scholar Rose declared at the start of his influential book, The Strategy of Preventive Medicine, “There is no known biological reason why every population should not be as healthy as the best” (Rose 1992, 1). He was well aware that this empirical and epistemic claim sets the stage for ethical and political work founded on a shared commitment to scrutinizing and fixing the social conditions that make some populations suffer more than their neighbors. In other words, health inequities between populations are not biological destinies; they are the results of political choices, ones that we can ameliorate if we find the collective will to do so.
The US lacks a culture of health, and that has shaped its creation of health system institutions—four of which are discussed here—that have long been badly flawed in ways that undermine public health. COVID-19 has greatly exacerbated the harms of those institutions, which have disproportionately hurt socially marginalized people in ways predicted by fundamental cause theory. This has led to an uncomfortable combination of knowns and unknowns regarding COVID-19. From the perspective of a scholar of the epistemology and ethics of public health equity and social conditions’ impacts on justice: I didn’t at all anticipate spending 2020 in lockdown, but when I read the unending stream of reports that COVID-19 is disproportionately harming socially marginalized populations that are relatively unprotected by the armor of fundamental causes—from low-income retail workers to residents of Navajo Nation—surprise rarely comes to mind.
I am grateful to Helen De Cruz for comments on this paper and to the participants of the 2020 St. Louis Area Philosophy of Science Association (virtual) conference for their comments on an earlier version of this work.
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 For the purposes of this paper, I will not delve into the disputes over the assumptions, theoretical commitments, and tacit or explicit empirical predictions/claims of “racial capitalism” (Robinson 2000), nor how it meshes with “intersectionality theory” vs. alternative accounts of the dynamics between racism, capitalism, classism, sexism, colonialism, and other forms of domination. For a partial review of the disputes, see the debate between Foley (2019) and Bohrer (2019) regarding how to interpret the intersectionality work of Collins (2019) and the intellectual contributions of Crenshaw (1989). Here, it suffices to note that racism, poverty, and other social disadvantages can be posited as fundamental causes, and disputes over how to delineate them or understand their interactions are matters for ongoing theoretical work and testing of empirical predictions.