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Under the Biden–Harris administration, there is renewed attention on inequalities in the USA that have exacerbated vulnerability to the COVID-19 pandemic and manifested as racial and class disparities in morbidity, mortality, and vaccination.1, 2 With public health now at the centre of national priorities, there is an opportunity to reverse the decades-long dismantling of US welfare systems that has weakened public health and exacerbated racial inequities.3, 4 As the US plans for pandemic recovery, we encourage the medical community to advocate for large-scale infrastructure investments to build systems of economic and social protection that are pivotal for pandemic preparedness and public safety.5 Physicians have long known that working conditions and economic security are key determinants of health. Unfortunately, many health-care systems, especially in the USA, have been designed around reductive, monetary notions of value that are in tension with principles of prevention, justice, anti-racism, and prioritising equitable care delivery.6 The dominance of reductively biomedical and economic emphases has generally cultivated narrow visions of the health-care community's proper purview and deflected physicians' political responsibilities to prevent disease and protect patients.7 During the COVID-19 pandemic, however, characterisations of effective care as apolitical or a matter of individual ethics rather than collective organisation have become increasingly untenable.7, 8

community's proper purview and deflected physicians' political responsibilities to prevent disease and protect patients.7 During the COVID-19 pandemic, however, characterisations of effective care as apolitical or a matter of individual ethics rather than collective organisation have become increasingly untenable.7, 8 Among the most consequential policies on which physicians can focus their influence are those that relate to labour protections, unemployment insurance, and housing. Political choices that shape workers' rights and income security have consequences for national infection control, global biosecurity, and related economic stability. As the pandemic has shown, neglect of this reality has severe downstream implications for the more than 2 billion people who live in poverty globally.9 In the USA, despite abundant wealth, public policy has not invested in adequate systems of economic protection and care for the country's most disadvantaged residents.

As the pandemic has shown, neglect of this reality has severe downstream implications for the more than 2 billion people who live in poverty globally.9 In the USA, despite abundant wealth, public policy has not invested in adequate systems of economic protection and care for the country's most disadvantaged residents. During the COVID-19 pandemic, essential workers have been publicly praised while simultaneously being treated as disposable—a reality that has deepened racial and gender inequities. Black, Asian, Indigenous, and Latinx women, for example, are over-represented among both those who have continued to work in high-risk settings and among those who have lost their jobs and endure the highest rates of unemployment.10, 11, 12 Moreover, nearly all US states overlooked the most at-risk essential workers––who, data show, are food, agricultural, transportation, facilities, and manufacturing workers, for example, not doctors13—in early COVID-19 vaccine distribution schedules.

ost their jobs and endure the highest rates of unemployment.10, 11, 12 Moreover, nearly all US states overlooked the most at-risk essential workers––who, data show, are food, agricultural, transportation, facilities, and manufacturing workers, for example, not doctors13—in early COVID-19 vaccine distribution schedules. The pandemic has taken advantage of a long-standing synergy––produced by policy––between structural misogyny, racism, inadequate welfare and labour protections, and epidemiology.13, 14, 15 In the USA, millions of workers have been infected and thousands have died from COVID-19. A disproportionate number of those subjected to risk are women and people of colour, especially among caregivers, such as nursing assistants and health-care assistants without high professional status.15 About 80% of health-care workers who have had COVID-19 in the USA are women, and health-care workers of colour are substantially over-represented among those infected.15, 16 This reflects the fact that minoritised women's labour, often drawn from immigrant populations, constitutes the base of caregiving in the USA, as in the UK and many other nations.17 In a US context more attentive to mantras of profit and economic growth than to care, and where 50% of residents fear bankruptcy due to a health event,18 the financial fallout from COVID-19 and the associated long-term disability for many will have considerable ramifications. Due to wealth, wage, and opportunity gaps, these impacts will hit women and people of colour especially hard.14 © 2021 Saul Loeb/Getty Images2021

The pandemic has taken advantage of a long-standing synergy––produced by policy––between structural misogyny, racism, inadequate welfare and labour protections, and epidemiology.13, 14, 15 In the USA, millions of workers have been infected and thousands have died from COVID-19. A disproportionate number of those subjected to risk are women and people of colour, especially among caregivers, such as nursing assistants and health-care assistants without high professional status.15 About 80% of health-care workers who have had COVID-19 in the USA are women, and health-care workers of colour are substantially over-represented among those infected.15, 16 This reflects the fact that minoritised women's labour, often drawn from immigrant populations, constitutes the base of caregiving in the USA, as in the UK and many other nations.17 In a US context more attentive to mantras of profit and economic growth than to care, and where 50% of residents fear bankruptcy due to a health event,18 the financial fallout from COVID-19 and the associated long-term disability for many will have considerable ramifications. Due to wealth, wage, and opportunity gaps, these impacts will hit women and people of colour especially hard.14 © 2021 Saul Loeb/Getty Images2021 These circumstances are politically determined, not accidents or surprises.19 Policies at local and federal levels have consistently fallen short of adequately supporting the USA's most marginalised populations. Alongside this reality, over decades, US medical institutions have acquired wealth and political influence enabled by revenue-driven health-care systems that have normalised inequities and barriers to access, resulting in tens of thousands of preventable deaths each year.20 Now, as the USA attempts to emerge from a pandemic that has exposed the inadequacy of its care infrastructures, the medical community has a vital opportunity to mobilise its political influence to oppose the continued exploitation of workers who so easily pass into the ranks of the unemployed, bankrupt, unhoused, sick, or dead.

he USA attempts to emerge from a pandemic that has exposed the inadequacy of its care infrastructures, the medical community has a vital opportunity to mobilise its political influence to oppose the continued exploitation of workers who so easily pass into the ranks of the unemployed, bankrupt, unhoused, sick, or dead. To safeguard public health, health professionals need to demand that policy makers effectively address the hardships faced by millions, not wait until those in already vulnerable situations fall deeper into desperation. Neither one-time US$1400 payments nor temporary eviction moratoriums while unpaid rent accumulates are adequate. We need ambitious structural changes––on the scale of universal health coverage and a guaranteed basic income––to a US economy that, as the enrichment of a few during the pandemic shows, serves the powerful by essentialising and disposing of those it makes weak through deprivation.21, 22, 23 The USA's inadequate welfare systems and workers' protections should be regarded as ethical and political failures that compel us to do better.24, 25 We need a bold new politics of care measured not by gross domestic product or stock market indices but by the financial wellbeing and health of our most marginalised residents.26 Such priorities are not only matters of ethics, equity, and justice, they are also essential for biosecurity, pandemic preparedness, economic resilience, and the stability of democracy.

not by gross domestic product or stock market indices but by the financial wellbeing and health of our most marginalised residents.26 Such priorities are not only matters of ethics, equity, and justice, they are also essential for biosecurity, pandemic preparedness, economic resilience, and the stability of democracy. To protect both health and the body politic in a polarised nation, physicians and their institutional leaders need to put principles of care into a political practice that extends beyond clinical domains to address the material conditions shaping the lives of our vulnerable patients. To fulfil the duty to care requires fighting for an economy that cares for all.