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Political limits

By the end of last year, initiatives such as the COVID-19 Equity Project in Fresno had cropped up across the United States. These programmes are now spearheading equitable vaccine distribution. But the projects are funded by short-term infusions of money. When that dries up, much of the work towards eliminating health disparities will fall back on the health system, says Banh.

But unlike grass-roots groups, officials in the US public-health system — comprising the CDC and health departments across the country — tend to avoid politically sensitive topics, such as calling for higher wages and immigration reform.

Government researchers have identified the social determinants of health during the pandemic, but they’re typically treated as immutable factors. For example, an October 2020 investigation5 in the CDC’s journal, Morbidity and Mortality Weekly Report, finds that Black and Hispanic people are disproportionately dying of COVID-19, possibly because of underlying diseases, dense households, in-person work, poor access to health care and discrimination (see also ‘COVID’s unequal toll’).

But instead of suggesting affordable housing, universal health care and labour protections, the report recommended masks, hand washing and social distancing.

Another CDC study6 posted online on 12 April finds that COVID-19 hospitalizations were highest for Hispanic or Latinx people in the United States, compared with other racial or ethnic groups. The authors attribute the disparity to the social determinants of health, and recommend that health departments distribute vaccines accordingly. But they don’t suggest ways to correct the underlying problems.

Ronald Labonté, a public-health researcher at the University of Ottawa in Canada, isn’t surprised to see government scientists dodging political flashpoints, because there can be severe consequences for speaking out — some have received death threats, for instance. Similarly, he says, public-health researchers often link poverty and marginalization to disease, but don’t challenge the status quo by digging deeper into why people are poor or marginalized in the first place.

“What drives it is essentially oppression, exploitation and the pursuit of power and profit,” he says. “But I don’t think you’re gonna have too many public-health departments come out and say that.”

This doesn’t mean that people in the public-health system don’t want to address systemic injustice. One obstacle is that health departments have limited control. For example, Fuller at Fresno’s health department says he can advise companies on best COVID-19 practices, but the department can’t enforce rules. “The safety and health of employees is not under our jurisdiction.”

Indeed, that duty typically falls to the Occupational Safety and Health Administration (OSHA), the US regulatory agency with the power to inspect workplaces to ensure that conditions are safe.

But if public health has been underfunded, OSHA’s resources are even more scant, and its powers are consistently undermined by business interests, says epidemiologist David Michaels at the George Washington University School of Public Health in Washington DC, who directed OSHA under former president Barack Obama. Last year, the number of OSHA workplace safety inspectors was lower than at any time in the past 45 years, according to the National Employment Law Project.

Perhaps this is why so few of more than 13,000 complaints to OSHA about coronavirus-related hazards were followed up with inspections and fines. “We have structured our economy so that many workers have few rights, and are underpaid, and face hazards that would be unacceptable to the corporate leaders who profit from their work,” Michaels says.

Singh’s mother lives that reality. Two weeks before she tested positive for the coronavirus at the Foster Farms meat-packing plant, she told her son that 140 people at work might have COVID-19. The factory floor looked emptier, she told him, and a flyer in English on the notice board included the number 140.

Singh didn’t know what to make of his mother’s fears. “I feel like everyone I know at Foster Farms speaks Spanish, Hmong and Punjabi, and like very few speak English,” he explains. He told his mother to ask a co-worker with a smartphone to photograph the sign, and send it to him to read. But her colleague refused because she didn’t want to get into trouble.

A couple of days later, she said the sign had disappeared — but the outbreak was silently growing larger. In December, the United Farm Workers of America union sued Foster Farms on behalf of several employees from a plant in Livingston, alleging that “Foster Farms has failed to take the necessary safety precautions to prevent the spread of COVID-19”.

In fact, Foster Farms’ Livingston plant is exceptional because it is one of very few agricultural businesses shut down by health-department officials for a COVID-19 outbreak.

Salvador Sandoval, an officer at the Merced health department — where Livingston is located — became upset when he found out that two employees had died at the plant in July. That prompted the department to request a list of all worker infections. “Buried in it were more people who were deceased,” Sandoval says.

He and the department’s epidemiologist were alarmed. They wanted to shut the Livingston plant until everyone could be tested. So they reached out to California’s health department and the state’s OSHA office for help as Merced’s leaders pushed back against the closure.

The health department even got a call from a federal official in mid-August, saying that the plant must remain open because of Trump’s executive order to keep meat-processing plants operational.

But Merced’s tiny department persisted. At the end of August, after eight workers had died, the Livingston plant partially closed for six days so that it could be cleaned, and workers tested. “It wasn’t easy,” Sandoval says. “This was blood, sweat and tears.”

In a statement to Nature, Foster Farms writes that the company is committed to the health and welfare of its employees, and that it has implemented COVID-19 protective measures throughout the pandemic, including an extensive testing system.

In February, the company began vaccinating California employees. And as for specific complaints from workers, the company writes, “Since March 2020, all company employees have been encouraged to share any concerns about their health and safety regarding COVID-19 with their supervisors.”

Protecting public health

Evidence on the toll of outbreaks at meat-packing plants has been undeniable. In a paper in Proceedings of the National Academy of Sciences7, researchers estimated that, in just the first half of 2020, up to 310,000 cases and as many as 5,200 deaths in the United States were due to outbreaks at livestock plants that spread through surrounding communities.

And those figures point to a larger problem. Public-health specialists are correct in saying that they don’t have control of workplaces, but when they can’t successfully push back against policies that favour corporate interests, historians say the field can’t accomplish one of its core functions — protecting the most vulnerable from disease.

“We know what the impact is of a lack of employment, a lack of fair wages, a lack of transport, of poor education and racism,” says Graham Mooney, a public-health historian at Johns Hopkins University in Baltimore, Maryland. “So, if public health has no power to influence these issues, then public health becomes nothing.”

Georges Benjamin, executive director of the American Public Health Association, agrees. He adds that the time to push for social and economic changes is now, when the tragedies of the pandemic have laid bare an urgent need for reform. He recalls how the devastation of the Great Depression in the 1930s led to the ‘New Deal’, a series of programmes that included unemployment insurance, housing reform and welfare benefits under former president Franklin D. Roosevelt.

“Once again, we need to come up with a new social compact for America,” says Benjamin. “One that says that everyone should have access to a living wage, to affordable housing, to affordable health care, that our environment should be safe.”

A month after I talked to Benjamin, US President Joe Biden proposed a $2-trillion economic plan that includes features reminiscent of the New Deal. It even echoes Virchow’s report on curbing typhus in Upper Silesia in the 1850s, with calls for higher wages, improved working conditions, public schools and affordable housing — paid for, in part, through tax increases on corporations. If enacted, proponents say, the plan could reverse 40 years of rising inequality in the United States.

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