The privilege of Swiss cheese versus the tragedy of the pandemic tunnel
In the fall of 2020 journalists Kate Cimini and Jackie Botts wrote a story about the danger of California’s overcrowded homes and the Covid-19 pandemic. The story opens with Isidoro Flores Contreras selling flowers on a street corner in Sand City, California near Monterey Bay. Mr. Flores Contreras is a heavy-set man who walks with a slight limp. His job is hard. He paces on street corners waiving flower bouquets that he sells to passing cars. He wears a hat and seeks shade under a nearby tree when the weather gets too warm. Buckets filled with more flowers sit behind him on the sidewalk. A sign reads $15. He earns about $300 per week.
After work each day Mr. Flores Contreras returns to a two-bedroom home in Alisal, CA that he shares with four other people. Mr. Flores Contreras sleeps on the couch while the other residents sleep in the bedrooms. Mexican and Mexican-American families populate the neighborhood where he lives. Many of them are essential workers employed in the agriculture industry. Alisal has high rates of poverty and suffers from many overcrowded homes that make it difficult to isolate when someone becomes infected.
Most of the cars that pass Mr. Flores Contreras while he works contain people living a life more privileged than his. They are driving expensive cars and pass a Mercedes or BMW dealership just before they reach his corner. Many journey to a local beach on Monterey Bay that sits not far where Mr. Contreras sells his flowers. The juxtaposition of his work and their life as they drive by sets a dichotomy that occurred frequently early in the pandemic. The advice that people received about how best to protect themselves in the midst of a pandemic made this dichotomy even more clear.
As the pandemic raged a common piece of wisdom arose that relied on the image of a common block of Swiss cheese. People were advised to layer a set of protections atop other protections so that when one protection failed another was there to protect them. Avoid crowded gatherings, wear a mask, isolate when you become ill, get vaccinated, seek treatment and test when you experience symptoms. The wisdom of the image comes from imagining each of these and other protections all being beneficial but not foolproof. Each has a hole like a piece of Swiss cheese, but if you stack several slices atop each other, together the holes rarely align; when one protection fails another succeeds. This wisdom from this metaphor was brought to international attention by Ian Mackay who built upon work by psychologist James Reason.
The Swiss cheese model has clear benefits. It applies as well to what was later called the “vaccine plus” strategy of pandemic mitigation – get vaccinated but continue to protect yourself, and by protecting yourself against infection you also protect others.
However, this strategy has a limit. Many of the protections that can be layered are not available to all. Consider Mr. Flores Contreras. Given his job, he likely lacks consistent health care which leads him to suffer from medical ailments. His limp is just one indication that he may not be fully healthy. It is likely that he doesn’t have employer provided health insurance. Most people of his income level are forced to seek healthcare at urgent care centers. They don’t have consistent primary care providers who know their health history well. Because of this he is more likely than someone with higher quality health care to suffer from an underlying medical condition that puts him at greater risk for hospitalization, or death, if infected. At his income level most of his income is taken up by rent, utilities and food. He almost certainly does not have extensive savings. Should he become ill he may have little choice but to continue working and commuting. It takes over an hour to reach his place of work from home on crowded public transit. Because of this he is more likely to become ill. Further, because of his crowded living conditions in a neighborhood with many essential workers, it is likely that someone in his home will become infected. Once this happens, where do they isolate? There is no room within their home to do so. Their income is too small to move to a hotel for an isolation period. On and on go his list of potential risks of exposure and potentially serious medical complications.
For a person who lives in conditions like Mr. Flores Contreras, the Swiss cheese model has little application. Instead of protection layered upon protection he faces risk layered upon risk. Instead of Swiss cheese he faces a pandemic tunnel that contains multiple levels of risk all directed upon him. It is as though people like him wear a pandemic target.
It is because he faces this pandemic tunnel, that those with more privilege need to do their best to avoid infections and epidemic spread. The only way for those without the privilege of Swiss cheese to remain safe is for others to protect them. That is our job. And it’s our responsibility to do those small things that I wrote about two weeks ago in order to keep him and others like him safe.
Troy Tassier is a professor of economics at Fordham University and the author of The Rich Flee and the Poor Take the Bus: How Our Unequal Society Fails Us during Outbreaks.