To begin, persons who are disadvantaged might be in grave physical danger of succumbing to SARS-CoV-2 due to an inability to protect themselves. Public health measures recommended or ordered during the COVID-19 pandemic often assume people are housed (e.g., “stay at home”), can maintain a certain distance with others, and have access to running water and soap (e.g., “wash your hands”), none of which are typically possible for those sleeping rough or living in congregate settings (e.g., shelters and refugee camps) (Tsai and Wilson 2020). Moreover, the immune systems of such persons may not be at full or normal capacity due to the lack of nutritious foods. Other marginalized populations will likely face other risks: migrants and refugees often have little-to-no access to primary healthcare or may be in a country illegally, which may result in their not seeking care for COVID-19 in a timely manner. In the case of prisoners, it may be impossible to isolate safely at all. Thus, although the current data on the matter are provisional (CDC 2020), there are reasons to believe that many marginalized persons are at greater risk of getting infected with SARS-CoV-2, developing COVID-19, and suffering more severe forms of illness than those in the general population due to underlying social and economic conditions.
In addition to potentially worse physical outcomes, social distancing itself risks negatively impacting marginalized persons in a number of ways. As a means of stemming the rate of infection related to COVID-19, we fully and unequivocally support social distancing initiatives as an effective and ethical measure. For the general population, the potential ill effects of social distancing are relatively well known and have been discussed regularly in the media, including the feeling of social isolation and the potential lack of physical movement from being indoors for longer than normal. Persons who are homeless, however, face additional risks related to social distancing. For example, they may not be able to access social services provided by governments or charities, or may be unable to go to shelters if they are closed. In cold-weather environments, this may also require either being subjected to the risk of infection by continuing to sleep in congregate settings, or risk the elements of winter, potentially with its own set of dire consequences (e.g., freezing to death). Another example would be the potential deterioration of migrant workers’ mental health, e.g., greater rates of depression during extensive periods of isolation, since mental illnesses exist at higher rates within these populations than in the general population (Liem et al. 2020). Migrant workers may be asked to leave their dwellings or might lose their employment due to the current economic downturn, and thus become homeless, then becoming subject to the risks associated with homelessness. Thus, there exists an extensive list of challenges that arise due to social distancing that disproportionately risks the well-being of marginalized persons, e.g., increased drug use, increased rates of mental illnesses, increased rates of domestic violence (Usher et al. 2020).
Finally, there is a tendency during emergencies, like pandemics, to resort to overly simplistic utility calculations in public health (e.g., maximizing best outcomes with little regard for their distribution between population groups) (Veatch 2005; Kirkwood 2017; Smith et al. 2019). In these contexts, saving the most lives possible seems to trump other ethics considerations like social justice concerns for the most disadvantaged. And while there are some instances when such decisions are perhaps justified (e.g., allocation of ventilators if they are scarce), even during emergencies we ought to include considerations in addition to mere utility (e.g., need or equity) to avoid further disadvantaging the already disadvantaged (Silva et al. 2013).
Therefore, as noted at the outset, many marginalized persons are subject to three forms of risk that compound during pandemics: the medical risks associated with COVID-19, the risks associated with social distancing, and the risks associated with an overreliance on the principle of utility during pandemics. Only the first of those three risks are shared by all members of a society, while the third risk may endanger other potentially vulnerable persons (e.g., the elderly with regard to the allocation of scarce medical resources). This requires special consideration for disadvantaged populations in the use of social distancing measures.
Social justice, then, requires taking into account not only the harms that occur in the context of addressing COVID-19 but also the risks to which people are subjected in the course of addressing the pandemic. Social justice requires not only the fair distribution of benefits and burdens but also the fair distribution of the risks of burdens (Wolff and De-Shalit, 2007). Public health, it has been said, holds social justice as its “core value” (Gostin and Powers 2006). It follows that public health ought to care about social justice as it relates to COVID-19. Therein lies the rub: if questions about the just distribution of benefits and burden matters to public health and global health, then we should also care about the just distribution of the risks associated with COVID-19 in relation to the measures implemented to arrest its spread. What we do not want to do is exacerbate inequalities, especially in those instances where there is no plausible justification to do so.