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Pandemic: Bigger than We Think—Part 3

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden Lundgren
February 5, 2020

The most important consideration in the causation of disease is the body constitution that becomes afflicted. Therefore, not all people will die during an epidemic.

~ Moses Maimonides, c. 1190

The only thing surprising about the inequities among groups of COVID patients was that they surprised so many people. Charles Rosenberg, the eminent medical historian, has remarked that epidemics can serve as natural experiments illuminating fundamental patterns of social value and institutional practice. Epidemics, in fact, can reveal what is most fundamental to a particular society.

The pandemic tore the lid off class disparities. It’s not a new thing. Arguably the most famous piece of plague literature is The Decameron by Giovanni Boccaccio. In 1348, ten gentlemen and women flee the horrors of the plague and retreat to a luxurious Italian palace where their biggest problem is how to entertain themselves. That account was re-enacted last year as nearly half a million New Yorkers, most from predominantly white, wealthy neighborhoods, fled the city, many to their vacation homes. In an analogous development, millions of Americans abandoned their offices to work at home. But many—so many of them low income essential workers—could not do that. And their employers were not required to provide safe working conditions. Many of the millions who lost their jobs had some government help at first, but ended up in food lines or worse.

Less noticed, but just as serious, was the disproportionate impact of the epidemic on women. Although men proved to be more likely than women to die of the virus, women were more likely to be exposed either through their jobs or as nursing home residents, 70% of whom are women. The work of the epidemic fell largely on women. One in three jobs deemed essential is held by a woman. Almost half are in healthcare, 89% of that workforce. 83% of healthcare workers who earn less than $30,000/year are women. 73% of the healthcare workers who have been infected are women.

Closed schools have added to the “second shift” work of women who were now expected to not only care for children, but to educate them too. For some women, this meant career interruption. Women of color are far more likely to be family breadwinners. For them, closed schools meant a scramble for childcare or job loss. Studies of earlier 21st century epidemics suggest that women never financially recover from the experience.

My students who came from cultures where elders are revered were shocked at American attitudes toward the aged. So often, seniors are simply discarded. 80% of COVID deaths have occurred in people over age 65. Nearly half of all women age 75 or older are living alone. (The figure for men is 22%.) Isolated living puts seniors at high risk for loneliness, a major mortality risk factor. Too often, advancing age or disability means consignment to a nursing home—nearly all of them run for profit. There are about 50 million people age 65 or older in the United States now. That will be 88.5 million in 2030. Nearly half of all COVID deaths in this country have occurred in nursing homes.  

As far as racial differences, the numbers tell it all. Indigenous peoples at died 1.8 times the rate for whites, Asians: 1.1, Hispanics and Blacks: 2.8. 43% of essential jobs were held by people of color, making them more exposed to the virus than at-home workers. My fellow columnists, Vanessa Lopez-Littleton and Carla Jackie Sampson reviewed the racial effects of the social determinants of health in their masterful pieces on this site last year (September 3, October 1, November 6). The results of persistent racial discrimination include conditions increasing risk of death from COVID and premature death overall: obesity, diabetes, cancer, hypertension, heart disease. COVID cases and death are higher in nursing homes with more patients of color. Over half of staff who provide direct long-term care are people of color.

65% of nursing home residents are on Medicaid, i.e., they are poor. Poor people are several times more likely to die prematurely than their wealthier counterparts, and poverty itself may make a person three times more likely to become ill with corona virus.

The intersection of class, sexism, ageism, racism and poverty has produced a death storm of infection in nursing homes. As Professor Rosenberg warned us, the epidemic has shown us who we are. Our question is what we do about it.

Just to put a pin in it—I had to scroll through dozens of pages of healthcare images until I found a practitioner of color.

What the people want is simple. They want an America as good as its promise.

Congresswoman Barbara Jordan, 1977


Author: Burden S Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA. She has served as a consultant to a number of non-profit groups. Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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