The United States is Unnecessarily Culturally and Institutionally Vulnerable to Infectious Diseases
In light of the COVID-19 outbreak we should take the time to reflect on these weaknesses and what we can do to rectify them.
Over the past week, a growing number of cases of COVID-19 contracted from unknown sources have been reported. While we had more time to prepare than China, South Korea, Italy, or Japan, America’s respite is over; our chances of managing to track and contain the outbreak are increasingly slim. Unreassuringly, the US government’s preparations have been fraught with reports of faulty tests, inadequate testing criteria, and insufficient training and protective measures for the HHS workers who risked exposure. In addition to the ineptitude and denial that characterize the initial response, other institutional and cultural factors make the US unnecessarily vulnerable to the spread of the novel coronavirus (and disease in general). Although it is too late to fundamentally alter either the institutions or the culture in which these vulnerabilities are entrenched, a proper examination of them now can reveal stopgap measures and help us prepare for the next health crisis.
America’s work culture has, for decades, promoted the spread of disease. Employees aren’t given the leeway to be unhealthy; 45% of Americans have no paid sick leave.[i] Compounding on this, between 60 and 78% of Americans live paycheck to paycheck and, according to the AARP, 53% of American households have no designated emergency savings.[ii] Americans will work sick because they don’t feel like they can afford not to do so. These problems compound when income is taken into account. Only 33% of the bottom quarter of earners have paid sick leave.[iii] Customer service jobs, which have the potential to spread diseases to a larger and wider swath of people than other jobs, lack paid sick time 58% of the time. Workers of these types of jobs, which don’t pay as well as professional jobs, are also less likely to have emergency savings. With COVID-19 the financial stakes are even higher than a common cold or influenza. Even if the vulnerable worker doesn’t end up contracting the illness, the prospect of a two-week quarantine, for many people, spells financial disaster. 20% of Americans are unable to cover even a weeks’ worth of household expenses in the case of an emergency.
The cost of lost income isn’t the only factor motivating Americans to work sick. Employees attempting to call in sick are often asked if they’re sure that they’re unable to work or told to come in anyway. 34% of Americans state that they have gone to work sick due to pressure from their employer.[iv] This happens across all industries including in ones in which it is strictly illegal. I know multiple food service workers whose managers have forced them to work in contravention of OSHA standards. Many businesses lack the excess staffing capacity to deal with an unexpected illness in the workforce. Supervisors and managers often employ guilt to convince the sick worker to come in and stress the additional burden that the sick worker’s absence will place on the remaining staff. Even when possible, reduction of capacity, for example, a restaurant closing a section, is often viewed more negatively by the management than having a potentially ill employee work. Commercial America has a demonstrated tendency to put profit in front of public health. Again, it is the service industry, where a sick employee poses the greatest transmission risk, which suffers the most acutely from this issue. Professionals can often complete some work from home or make up missed work by working longer hours after they recover; service businesses cannot simply make up for the missed business at a later date.
With all of these factors taken into account, it’s no wonder that 90% of Americans admit to working sick.[v] Another driver of this trend is doctor’s note policies. While they appear to make sense from the employer’s perspective they fail in their basic premise. Instead of only sick employees staying home and healthy ones being unable to abuse false claims of illness, they drive employees to work sick. A sick employee may view the hassle of a clinic or urgent care visit to be just as draining as just going to work. To make matters worse, requiring employees to procure sick notes forces financial considerations into the equation yet again. Not only is a day of income lost but barring adequate insurance or employers willing to cover the cost, sick note policies force unhealthy workers to pay not to work. Even in Canada, where the cost of sick notes is cheaper if not free, eight out of 10 workers reported that they would go to work sick if employers require doctors’ notes for minor illness.[vi] Not only are doctor’s note policies ineffective from both the perspective of the employee and the employer (who loses productivity when disease ravages the office), but they fail from a public health perspective as well. These policies cause excessive traffic to hospitals and urgent care facilities resulting in the expenditure of resources on illnesses that may not need attention. Unnecessarily increasing the traffic to these facilities also risks putting immunocompromised patients in contact with contagious people (and exposing the sick employees to other diseases).
The culture of working sick isn’t the only way in which Americans are culturally susceptible to the spread of disease. High medical costs, the same ones that contribute to the failure of doctor’s note policies, make people hesitant to visit a doctor when they could just wait a few days and see if their condition improves. Under the right circumstances, this approach would be fine. Combined with America’s culture of working sick, however, it means slower recoveries and an increased chance that infectious diseases will be spread. Workers have no way to know if they are contagious or not if they are unable to access medical resources. In the context of the coronavirus, healthcare costs can, and likely will, hamper efforts to stymie the outbreak. Contact tracing and proper quarantine can only be undertaken when the case enters the healthcare system and is detected. When it comes to COVID-19, the fears of medical bills are compounded by the lack of available testing. While coronavirus testing is reportedly free, if a hospital does not have access to the tests to confirm the diagnoses then they will have to use other methods to try to rule it out. Additionally, CT scans are currently more effective at diagnosing the novel coronavirus than lab testing.[vii] Unlike the testing, these scans are not, by any stretch of the imagination, going to be free. Already, the story of a Florida man who had to pay $1,400 out of pocket as a result of his concern that he may have been infected has made the rounds around the internet. That man (who, it should be noted, had insurance) made the right choice, but after hearing the financial cost of his decision, others may be less likely to.
The bad news for Americans doesn’t stop there however, we don’t even wash our hands properly. One USDA study of consumers found that 97% of participants failed to correctly wash their hands, usually doing so for far too short for it to be effective.[viii] Relying on that statistic alone, of course, presumes that a handwashing attempt is even made at the proper time. Other studies have found that as many as one-third of Americans don’t bother to wash their hands after using the bathroom.[ix] The CDC recommends both hand washing and not touching one’s face as the most important preventative measures to protect against the coronavirus; given the state of American handwashing, we better hope that we’re better at not touching our faces.
So far, I’ve listed a lot of problems but not yet touched on any solutions. As always, identifying the problem is far easier than implementing a solution, and, as with every other issue, the solutions are debatable. One clear possibility, though, is paid sick leave. Keeping sick employees at home is not only good for the employee but also for the business. In addition to being less productive and a risk to other employees, sick employees are more likely to be injured in the workplace. This paid sick leave shouldn’t require a doctor’s note but rather function on trust. Yes, a system like this has the potential for abuse, but a fair number of days should just be considered part of the compensation package. This isn’t just good for the employees but the employer as well, access to paid sick leave decreases the probability of job separation by 25%.[x] Employees feel more valued and respected when they are trusted to make judgment calls, especially about their own health; let them decide whether or not they need to see a medical professional or just rest up.
Of course, this structural change will be wholly ineffective if the culture around working while sick doesn’t change as well. Admittedly, it may be difficult for most businesses to strike the proper staffing balances that allow for unexpected absences but do not result in overstaffing that negatively impacts the workers’ abilities to get hours. The simplest solution that doesn’t require compromising public health for service quality is capacity cutting. Admittedly, this is less than ideal from a financial standpoint and seems daunting at high volume businesses. The solution to this is that we normalize communicating issues, such as low staffing, to the customers. Everyone already knows that businesses are hiding harsh realities behind a polished veneer of projection. It’s about time that businesses drop some of the façade and instead communicated to establish accurate expectations in the customers’ minds. Are things going to be running slightly slower? Will there be fewer seats available? Just tell the customer. Either of those options should be viewed as far more acceptable as risking public health just to maintain the semblance of normal operations.
These policy changes need to come from the top-down, otherwise, managers will still feel the pressure to insist that sick workers place themselves and others at risk. Compassionate managers may be able to make a small difference but large scale changes cannot and will not happen without upper echelon support. It is impossible to simultaneously claim to trust on-site managers to make the right calls in these situations while exerting pressure from above which incentivizes making risky decisions.
One of the most effective domestic responses that I have seen so far is the decision by the state of New York to direct insurance companies to, “waive cost-sharing associated with testing for novel coronavirus including emergency room, urgent care, and office visits.”[xi] This is a bold step that will make testing more accessible for many. Unfortunately, steps like this taken during emergencies are limited in their efficiency compared to having a healthcare system where low or no cost accessibility is a permanent feature. The effectiveness of this measure will depend upon the quality of the messaging campaign notifying New Yorkers of these changes. There are also holes in this effort. The waived costs do not apply to New Yorkers whose plans are not regulated under the Employee Retirement Income Security Act of 1974 (ERISA).[xii] Additionally, the directive also does not help the uninsured access care.
The US response to the novel coronavirus is also being handicapped by exceptionally low trust in the government response. Mixed messaged, concerns about the competency of the leadership, and early mistakes have plagued the response so far. News stories and official releases urging concerned citizens to not hoard facial masks have been met with downright cynicism and supply shortages are imminent. This is not just a symptom of a lack of trust in the Trump administration but a result of years of waning trust in government and each other.[xiii] Rebuilding trust in the government, an impossible task to complete in the short term, would drastically improve the effectiveness of the messaging campaigns necessary to help the public understand and mitigate the threat of a disease like the novel coronavirus.
For now, we must play the hand that we have been dealt. As the situation worsens we see panic shopping for everything from N-95 masks (which have essentially no benefits when used by the untrained), to rubbing alcohol, to toilet paper. When this all ends, I suspect, much like Dr. Fauci, that we will look back “and say, boy, that was bad.”[xiv] This won’t have been the first bad outbreak in America’s history, nor will it be the last. It’s never too early to start preparing for the next one, and while we do so, I strongly suggest that we take the necessary actions to alleviate our unnecessary cultural and structural susceptibilities to the spread of disease.
[i] Lela Moore, “‘I Never Take a Sick Day’: Americans Talk About Reporting to Work When Ill,” New York Times, January 15, 2019, https://www.nytimes.com/2019/01/15/reader-center/sick-day-employment-policy-united-states-em.html.
[ii] Emmie Martin, “The government shutdown spotlights a bigger issue: 78% of US workers live paycheck to paycheck,” CNBC, January 9, 2019, https://www.cnbc.com/2019/01/09/shutdown-highlights-that-4-in-5-us-workers-live-paycheck-to-paycheck.html; “Unlocking the Potential of Emergency Savings Accounts” AARP Public Policy Institute, October 2019, https://www.aarp.org/content/dam/aarp/ppi/2019/10/unlocking-potential-emergency-savings-accounts.doi.10.26419ppi.00084.001.pdf
[iii] Heather Hill, “Paid Sick Leave and Job Stability,” Work and Occupations 40, no. 2, (November 2012) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3825168.
[iv] Abigail Hess, “A sobering stat during coronavirus fears — 90% of employees admit they have gone to work when sick,” CNBC, November 3, 2019, (title and story updated February 28, 2020), https://www.cnbc.com/2019/11/03/90percent-of-employees-say-they-come-to-work-sickheres-how-to-fix-that.html.
[vi] Megan Collie, “Asking an employee to get a sick note is a ‘public health risk,’ experts say,” Global News, October 6, 2019, https://globalnews.ca/news/5985336/employers-sick-notes.
[vii] Radiological Society of North America “CT provides best diagnosis for COVID-19,” ScienceDaily, February 26, 2020, https://www.sciencedaily.com/releases/2020/02/200226151951.htm.
[viii] “Food Safety Consumer Research Project: Meal Preparation Experiment Related to Thermometer Use,” Food Safety and Inspection Service, May, 2018, https://www.fsis.usda.gov/wps/wcm/connect/1fe5960e-c1d5-4bea-bccc-20b07fbfde50/Observational-Study-Addendum.pdf?MOD=AJPERES
[ix] Katie Zezima, “For many, Washroom Seems to Be Just a Name,” New York Times, September 13, 2010, https://www.nytimes.com/2010/09/14/us/14hands.html.
[x] Heather Hill, “Paid Sick Leave and Job Stability,” Work and Occupations 40, no. 2, (November 2012) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3825168.
[xi] “Governor Cuomo Announces New Directive Requiring New York Insurers to Waive Cost-Sharing for Coronavirus Testing,” Goveronor.ny.gov, March 2, 2020, https://www.governor.ny.gov/news/governor-cuomo-announces-new-directive-requiring-new-york-insurers-waive-cost-sharing.
[xiii] “Public Trust in Government: 1958–2019,” Pew Research Center, April 11, 2019, https://www.people-press.org/2019/04/11/public-trust-in-government-1958-2019.
[xiv] Sarah Owermohle, “‘You don’t want to go to war with a president,’” Politico, March 3, 2020, https://www.politico.com/news/2020/03/03/anthony-fauci-trump-coronavirus-crisis-118961.