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KERA's One Crisis Away project focuses on North Texans living on the financial edge.

Coronavirus Spread Illustrates How Inequality Complicates Public Health

doctor's office
More than five million Texans don't have health insurance, and about 40% of Texas workers don't have paid sick leave.

This story is part of the KERA One Crisis Away series, Coronavirus And Life On The Financial Edge.

The fast-spreading coronavirus pandemic is putting into sharp focus the ways inequality makes responding to disease outbreaks more challenging. As public health and other officials seek to limit the spread of the virus, the decisions they make and the guidance they offer may be undermined by the large number of Texans living on the financial edge.

Some of the guidance for keeping safe and slowing the spread of the novel coronavirus is easy for most people: Wash hands thoroughly and often, cough into an elbow or a tissue, avoid touching your face. Other advice can be trickier to follow, like telling people who may have been exposed to stay home from work, or go to the doctor if they have symptoms.

“That seems like a very fair thing to ask people, when we’re in the middle of an epidemic,” said Erin Carlson, who directs the graduate public health program at the University of Texas – Arlington. “But, if you do not have health insurance, if you do not have paid sick leave, that’s a very difficult thing to actually do.”

More than five million Texans don’t have health insurance, so they may not have a primary care doctor to call. Even more Texans are underinsured, which can leave people wondering if they can afford to get tested. And about 40% of Texas workers don’t have paid sick leave. Many of them, like home health aides and restaurant workers, have jobs that put them at particular risk of contracting or spreading viruses.

“If your child is sick, how are you going to stay home and take care of that child, if you don’t have sick leave? So the more likely scenario is, you send the child to school sick because you cannot afford to lose those wages” Carlson said. “Or if you feel sick, you’re going to continue to work because you can’t afford to lose those wages.”

Paid Sick Leave

People generally want to follow public health guidance and keep their communities safe, Carlson said, but for many, it’s a choice between the lesser of two evils. The U.S. stands apart from other wealthy, industrialized nations because it doesn’t require sick leave or guarantee health care, and Carlson said that presents a challenge to the public health systems that respond to pandemics like coronavirus.

During the 2009 H1N1 influenza outbreak, researchers found that sick leave and other workplace policies contributed to an additional five million cases in the U.S. An estimated 60.8 million Americans contracted the disease, according to the Centers for Disease Control and Prevention. 

After Dallas, San Antonio and Austin passed city ordinances in 2018 requiring employers to offer paid sick leave to workers, businesses backed by the conservative Texas Public Policy Foundation and top state Republicans launched lawsuits to overturn the ordinances arguing that only the state has the right to require paid leave. In Austin and San Antionio, federal courts temporarily blocked the enforcement of the new rules while the lawsuits play out. In the Dallas case, a judge hasn’t ruled on a similar injunction, so the law went into effect and will begin being enforced April 1. 

“We have fantastic public health preparedness in the United States, and in North Texas hospitals we are remarkably well prepared for this disease, I have no fear about that,” Carlson said. Instead, she worries “people won’t use those resources if they perceive they can’t afford them.”

State and federal governments are trying to respond. Texas Gov. Greg Abbott has asked insurers to waive fees for testing for Covid-19, the disease caused by the novel coronavirus. Other states like New York are looking to use Medicaid funds to fully cover testing costs, andpublic health clinics and hospitals continue to treat people who are low-income or uninsured.

Coronavirus’ spread has spurred some businesses, including the parent company of Olive Garden, to extend paid sick leave to hourly workers. Walmart, the nation’s largest private employer, expanded paid sick leave for those who test positive for Covid-19; so did Target. In Washington, the House included federally funded paid leave for workers impacted by the disease in its emergency coronavirus bill, though the policy would exempt millions of workers. The Senate is expected to take up the legislation this week.

Family And Housing Challenges

But there are more challenges. Many low-income people, for example, can’t afford to buy multiple weeks’ worth of food, household essentials, and necessary medications in case they need to stay home because they’ve been exposed to coronavirus.

School and daycare closures send parents searching for alternatives, and may force some to stay home and lose income. It also means kids who rely on school are at risk of going hungry. 

“They eat breakfast at school, they eat lunch at school, and a lot of school districts have pantries for kids that they can take home, some non-perishable foods to make it through the weekend,” Diana Cervantes said. She’s a public health professor from the University of North Texas Health Science Center, who used to work for Tarrant County Public Health and the Texas Department of State Health Services.

“That was a big lesson learned during the 2009 flu pandemic,” Cervantes said. “How are we going to still distribute food to these kiddos that rely on the school lunch programs, and how are we going to do it in a way that doesn’t mass gather people to give out food.”

Fort Worth ISD and several other North Texas school districts are providing grab-and-go meals for kids at limited school locations, and Dallas ISD has switched its spring break meal program to only providing to-go options. 

Homelessness also presents a host of additional challenges for health officials working to reduce the spread of coronavirus. There hasn’t yet been a reported case of a person who is homeless contracting Covid-19 in North Texas, but Cervantes said there are a range of potential challenges: People who are homeless don't have consistent access to hand-washing or hand sanitizers, many have chronic illnesses that could exacerbate Covid-19 symptoms, and shelters don't have facilities for individuals to quarantine themselves.

“When people are resource-strapped, they are resource-strapped across the board, so it seems like it does affect everything,” Cervantes said. 

Previous disease outbreaks have made public health officials better at navigating these challenges, Cervantes said. Public health departments tap nonprofits to make sure people’s basic needs are met. They reach out to employers to make sure jobs are secure when a worker needs to be quarantined. When Ebola came to Dallas, Cervantes said epidemiologists even delivered formula and diapers while monitoring people in isolation.

“I think when you work as an epidemiologist and you’re working with disease prevention control, it becomes part of your daily life dealing with people who don’t have resources and how are you going to do that,” Cervantes said.

One good thing Cervantes said she’s seeing in the coronavirus response: There’s been more discussion early on about how to help people on the financial edge ,who are vulnerable to more than just the disease.

Christopher Connelly is a reporter covering issues related to financial instability and poverty for KERA’s One Crisis Away series. In 2015, he joined KERA to report on Fort Worth and Tarrant County. From Fort Worth, he also focused on politics and criminal justice stories.