Credit: AFP via Getty Images/JOEL SAGET

When Rudy Giuliani tested positive for the coronavirus, he didn't want to go to the hospital. He figured that, despite his 76 years, he'd be fine. But President Donald Trump's physician persuaded him to take advantage of one of the perks of being the personal lawyer to the commander in chief. "Don't be stupid," Giuliani said the doctor told him. "We can get it over with in three days." At the hospital, Giuliani received an experimental antibody treatment that most patients can only dream of. He recovered quickly.

While the coronavirus has buffeted us all, it has disproportionately ravaged the most disadvantaged members of society. That's because poorer people are more likely to be essential to the everyday working of our economy, and our health-care system tends to leave them underserved. In our market-based system, the rich get more care and better care. If you're wealthy, you're a priority — it is a form of power.

And as we deploy the new coronavirus vaccines, the powerful are going to seek the superior access to which they are accustomed and believe themselves entitled.

In the early stages of a mass vaccination effort, two groups are most important: those most likely to die of the disease if they get it, and those most likely to contract and transmit it. Wealthy people who aren't front-line workers should be a relatively low priority. They are among the most capable of mitigating the dangers of exposure for themselves. Most can get their groceries delivered without any social contact. They are more likely to work the kinds of jobs that can be performed remotely. When it comes to early access to a vaccine, a chief executive is far less essential than a pharmacy clerk and far less at risk than someone imprisoned and awaiting trial.

But we're about to see the wealthy try to jump to the head of the line. We know that partly because researchers studying the behavior of the rich — whether it's looking at their charitable giving on their tax returns or seeing how they take turns when driving around town — consistently find that wealthy people are more likely to be selfish and act unethically.They are more likely to think of themselves as more important than other people and less likely to give to others, according to studies. Our private health-care system amplifies, rather than moderates, these tendencies. Wealth gives people enormous leverage over our institutions and influence over our policies.

We've already seen these dynamics play out globally. Wealthy countries representing just 14% of the world's population have used their resources and influence to capture 96% of Pfizer's vaccine and 100% of Moderna's, according to a report by Oxfam and other human rights organizations. These nations are even planning on stockpiling extra, just in case. And because of this, it's estimated that billions of poorer people in less-advantaged nations will not receive the vaccine for years. This isn't just a profound moral failure. It also means that as those poorer workers move around the world to do work like farming that keeps us all alive, the risk of localized outbreaks will increase.

The habits of the powerful will also shape vaccine deployment within nations. After front-line health workers get their doses, the temptation — and opportunity — will rise for the wealthy to cut in line.

Doctors and hospitals already have incentives to cater more to those who can pay more. That's because market systems are designed to respond to wealth, not morality or the collective good. In Los Angeles, the Ronald Reagan UCLA Medical Center sells access to "executive health services." It will literally give you a gold card with a private number, and when you need care, doctors whisk you away into prioritized service, special areas of the hospital and additional treatments. During the pandemic, doctors have advertised the many advantages of "concierge medicine," the most exclusive of which can cost well above $5,000 per month: eliminating any wait for an appointment, access to international specialists, having a physician come to you and avoiding the need to sit in a waiting room with people who might be sick. These concierge suppliers are also reportedly using their wealth and connections to try to get early access to vaccines. Some are using the vaccine as a marketing opportunity, advertising that they "will be among the first" to get the shots and give them to their clients, as one Los Angeles-based practice put it.

Wealthy people are likely to make the case to their physicians that they should be categorized as "at risk" to be prioritized for the vaccine. Those doctors are likely to acquiesce because they're responsive to many things: insurance plans that pay more — or, even better, cash payments with no insurance-set rates; the necessity of referrals from "high value" patients; or simply the discomfort of having to say "no" to someone who's used to hearing "yes." Hospitals, dependent on big donors and those who pay them for special treatment, too, will make exceptions to get a few "high value" individuals what they want.

These exceptions will soon pile up to be the rule. We've seen this time and again. Wealthy parents, for example, are more likely to find health professionals to designate their children as disabled. In some rich school districts, children are 12 times more likely to be classified has having a disability than those in poor districts, giving them extra time on tests and thereby allowing them to perform better. Designing and then gaming the system is one of the perks of power.

The coronavirus has absolutely ravaged the most vulnerable; the wealthy, by contrast, have fared relatively well. As they use their every advantage to jump ahead of more disadvantaged and more essential workers, they will augment the inequalities that have increased during the pandemic and put our collective well-being at risk. Long ago, public health established that asking or even berating people to act better is a losing strategy. Instead, we need systems and institutions that are designed to produce the outcomes we want. With the coronavirus vaccine, we will see yet another way that our market-based health-care system is, quite literally, killing us.

Khan is a professor of sociology and American studies at Princeton University. This piece was written for The Washington Post.


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