The two worlds of social distancing
April 3, 2020
As I entered the third week of self-isolation in my home in East London, news of the first death from COVID-19 in Rio de Janeiro arrived on my smartphone. She was a sixty-three-year-old woman, a domestic servant, caring for her boss. The boss had just returned from an international holiday in Italy infected with the virus. Like many wealthy Brazilians, the boss must have seen nothing wrong in “self-isolating” alongside her servant. For the domestic worker, self-isolation was of course never an option. “If you don’t come to work, you don’t get paid”—as simple as this. The case offers a stark example of the perverse interaction between pandemics and inequalities. Depending on the scale of inequalities in your society—the real social distance—and where you stand economically, your chances of riding out a pandemic will vary significantly. The poorer you are, the worse your prospects will be.
This is because, as is now well-known, pandemics are not equal-opportunity events. The poor bear a disproportionate burden of morbidity and mortality, explained by three overlapping and reinforcing disadvantages caused by poverty: differential exposure, differential susceptibility, and differential access to healthcare. Differential exposure results mainly from unfavorable living conditions (e.g. overcrowding, lack of access to sanitation and clean water), but also from adverse working conditions (e.g. lack of paid sick leave, lack of protective equipment) and lack of education on how to avoid risky behavior when at all feasible. Differential susceptibility derives from worse underlying health conditions associated with poverty, such as malnutrition, psychological stress, high blood pressure, diabetes, and heart disease. Differential access to health care, caused by lack of private insurance, limited access to public services or ability to adhere to treatment, completes the triad of disadvantage. In short, the poor are more exposed and susceptible to disease, less capable of accessing healthcare when they catch it, and thus more likely to pass it on.
Previous pandemics have left plenty of evidence of this negative feedback loop. The HIV-AIDS pandemic provides a sobering illustration: Its 32 million deaths and 75 million infections so far have disproportionately burdened the poorest across and within countries. Of the 37.9 million people currently living with HIV across the world, more than one third have no access to antiretrovirals, most of them from Western and Central Africa, Asia, and the Pacific. The vast majority of the 1.7 million new infections still occurring every year take place in poor countries and poor areas within rich ones. In the U.S., HIV prevalence among the urban poor is 2.1%, more than double the 1% cut-off that defines a generalized HIV epidemic and found in badly affected poor countries such as Burundi, Ethiopia, Angola and Haiti.
What is true of HIV-AIDS repeats itself in other pandemics. To cite just one other example much closer to COVID-19, studies have shown that the 2009 H1N1 influenza killed three times more among the poorest 20% than among the richest 20% of the population in the UK.
We can expect socio-economic inequalities to keep playing a decisive role in how the current pandemic develops everywhere. Here in the UK, the curse of inequality was plain during the first days of the quarantine. Many were surprised to see the London underground teeming with people the day after the Prime Minister’s television address on March 23 urging everyone to stay at home. A survey of 2,108 UK adults brought to light the most obvious explanation. Only 44% reported being able to work from home, and this average varied significantly between managerial and professional workers (60%) and manual, semi-skilled, and casual workers (19%). It goes without saying that those with greater difficulties working from home tend to be also the lowest paid. In the U.S., during the 2009-2010 H1N1 epidemic that killed more than 12,000 Americans, three in 10 workers with symptoms continued going to work despite social distancing advice, driving 27% of all infections.
The UK government did realize, even if belatedly, that mere pleas for “social distancing” would not work under such circumstances, finally adding to its crisis package a grant to help millions of low-paid self-employed people who were still unsure about how to quarantine and put food on the table at the same time. But the help is arriving only in early June—a wait many cannot afford, just like millions of poor Americans now facing several weeks delay to get the $1,200 granted in the stimulus package of March 27. The burden on the limited unemployment benefits system has already been felt, with nearly a million new claims made in just two weeks (ten times more than the average). In the U.S., claims for unemployment benefits also surged from 282,000 to 3.3 million in one week, and now doubling to 6.6 million a week later.
Similar emergency measures are being implemented across the developed world, indicating that the vicious cycle between inequality and pandemics can be at least minimized through compensatory measures when the political will is there. (Sometimes, it isn’t.) But in less affluent and more unequal societies the problem is much more complex and dramatic.
In overcrowded living conditions such as those of favelas in Brazil, where many domestic servants and other low-paid workers and the unemployed live, the prospects are the worst possible ones. In the despairing words of Gilson Rodrigues, community leader in Paraisópolis, the largest favela of São Paulo:
“It is here that we will have more cases [of COVID-19], in the favelas. How can an old person self-isolate in a house with ten people and two rooms? This isolation is a joke; it is for the rich. The poor cannot do it. We are going to lose a lot of people in the favelas, sadly.”
I heard similar outrage from my friend Leonardo, self-quarantined in Rocinha (Rio de Janeiro), the largest favela in Latin America. “The TV in Brazil thinks everyone is rich,” he complained. “They offer tips on how not to gain weight during the quarantine! On how to use the playground of the gated condo safely! Here in the favela people will not stay inside. When the hunger hits things will become tragic.”
To compound the problems of lack of income and cramped accommodation of the 13.6 million people who live in favelas in Brazil, most lack access to basic sanitation and many suffer from constant interruptions in water supply. It is hard to envisage how people living under such conditions will be able to follow self-isolation for long when even washing hands is a struggle. According to a recent survey with 1,142 residents of 262 favelas across Brazil, 86% would not be able to withstand a month of quarantine without going hungry.
The Brazilian political establishment has not remained totally oblivious to the impending calamity. After a lot of negotiation, a grant of R$600 (60% of the minimum wage, US$115) was approved in the lower house of the Congress for a period of three months for those unable to earn above a certain threshold due to the COVID-19 crisis. Yet, because of its meager value, as well as inexorable difficulties and delays in getting the money to those who need it, the suffering is likely to be minimized at best.
There are certainly many more dramatic cases than the Brazilian one, such as the situation in India and its 45,000 stranded migrant workers. And some countries will of course be better than the British in terms of responses to the pandemic, such as New Zealand, whose package to help those unable to work from home is impressive. But everywhere, at varying degrees of intensity, the negative feedback loop between pandemics and inequality will show its ugly face.
As I brace myself for another week of quarantine, I crave not only for the end of the crisis but for the arrival of lessons that we may learn from it. Without diminishing significantly the stark social distance that separates us in normal times, each new pandemic will remind us that we are not, in fact, all in this together.
Octávio Luiz Motta Ferraz is a Brazilian legal academic at King’s College London, co-director of the Transnational Law Institute, and author of Health as a Human Right: The Politics and Judicialization of Health in Brazil (Cambridge University Press, forthcoming 2020).
Graphic by Bianca Ibarlucea.