When you’re too sick to go to work, you shouldn’t be punished for taking time to recover. That simple truth has driven many cities to enact paid leave policies in recent years, guaranteeing paid sick days, or some kind of paid medical- and family-leave time, as standard workplace policy. But those vital policies are still not available to everyone, which is having wide public-health ramifications: Working families most in need of paid time off are both disproportionately poor and more vulnerable to illness, and it costs everyone collectively an extraordinary amount of time and money.

A case study of a children’s hospital in Cincinatti, a racially divided city hit hard by the recession, has linked respiratory health, concentrated poverty, and days spent in hospital. Over a period of several years, 2011 to 2016, young children spent a disproportionate amount of time not at home or in school, but confined to a hospital ward, isolated and struggling just to breathe. A periodic episode of hospitalization might seem like a small inconvenience, but over time, when spread across a community, the struggle to breathe can consume years of the lives of local children.

Comparing poor and wealthy census tracts in one urban area, researchers concluded, “If children from all of the county’s census tracts spent the same amount of time in the hospital each year as those from the most affluent tracts, approximately twenty-two child-years of hospitalization time would be prevented.”

With millions of parents across the country unable to take a single paid day off work to care for a sick child—and working poor women have the least access to paid leave time—the Cincinnati study illuminates a pervasive unmet medical need; not just an occasional day off with a cold, but the cost of monthly emergency-room visits, the strain of rushing from work to pick a child up when she’s discharged, missing a night shift to tend to a wheezing preschooler overnight. In neighborhoods plagued by tragically preventable illnesses, high concentrations of (perhaps unnecessary) hospitalization means the city pays one way or another: spending more to deal with poor households’ added medical needs, or investing in policies focused on prevention and management of chronic conditions. When illness is concentrated in a neighborhood, the accumulated medical burden depletes overall community wealth and erodes public health.

In this social context, paid sick days make sense as a basic policy that alleviates health and wealth inequality, by addressing the long-term demand for care in communities where poor health is rife, and ensuring that individual families dealing with a medical crisis that stems in part from poverty aren’t forced to lose income in order to recover efficiently and with dignity. According to one of the coauthors of the study, Andrew Beck, associate professor of pediatrics at the University of Cincinnati College of Medicine, “a sick leave policy, or a policy that more effectively allows parents [or] caregivers to ensure completion of preventive services for their children, could have an effect on disparities in hospitalization rates.”

That might mean parents have to spend less time shuttling to and from hospitals and clinics, or they can stay home with a child to stabilize her condition to avoid going to the hospital altogether. And paid time off from work means recurring respiratory problems don’t eat into a family’s grocery budget or make it harder to pay the heating bill.

Ohio currently has no mandatory paid-leave policies that cover the whole workforce, but Beck believes the findings echo his own experiences dealing with the costs of chronic childhood disease, noting that “anecdotally, as a clinician, I have seen the stresses of work interfere with a parent’s ability to remain at a child’s bedside and to have an easier transition home.”

His previous research on children’s hospitalization, he adds, suggested that in neighborhoods suffering high asthma rates, for their caregivers, “work schedules were often unpredictable or inflexible.” In the case of an emergency like an asthma attack, he adds, “At the least, this seemed to add stress to the family’s experience. At the most, it interfered with safe, healthy transitions from hospital to home.” On top of that, families absorb the long-term emotional and social strain of instability that surrounds lives of constant precarity.

A growing body of research shows that health, race, and place are intimately connected. The National Bureau of Economic Research’s recent research on families in New Jersey found that areas with dense concentrations of poverty, or of people of color, are also the places with the most toxic air. With so much of childhood development linked to environmental conditions, researchers found that “black ZIP codes are less healthy places for all children and that much of the gap in asthma rates between African-American and other children…is attributable to their place of residence.”

The trend reflects general health disparities across social divides, but also brutally exposes subsurface environmental racism. After generations of housing segregation relegating the poor to the places where the rest of society dumps its waste, toxins, and smog–these disproportionately black ZIP codes have accumulated extreme levels of air pollution.

Ohio also reflects background factors that affirm the experiences of the children in the study: Overall, poverty correlates with poor-quality housing. Economic segregation through structural labor inequality relegates the poor, especially women and single mothers, to substandard jobs that lack benefits and flexibility. All these pressures make paid sick days that much rarer, and that much more needed, for working-class families.

These “social and structural determinants of health,” Beck explains, shape children’s lives, as well as their health. Environmental harms scar children’s lungs from the moment they’re brought home from the maternity ward, and drive them back to the hospital again and again in the coming years. Families bear the social and economic cost of being unhealthy, which breeds more illness, and they’re increasingly distanced from the quality of a family life that remains mostly the province of the privileged. A paid sick day won’t fix a life of everyday deprivation, but it can provide an invaluable moment of respite in a family’s lifelong struggle against a toxic environment.