Amid the swelling national conversation about income inequality comes a new report spotlighting that the lack of mandatory paid sick leave in the U.S. disproportionately burdens Hispanics and low-wage workers, including the vast majority of food service employees.

Forty percent of employed U.S. adults, or about 51 million people, get no paid sick days, forcing them to choose between a paycheck and time off to nurse the flu, take care of a sick family member or visit the doctor, and sometimes risking the loss of their job, according to a report out Wednesday from the nonprofit Institute for Women’s Policy Research.

Those who do have sick time barely use it. Forty-five percent of workers with paid sick days had not used any in the previous 12 months; 5 percent had used 11 or more days. Among those with paid sick days who took fewer than 11 days off (this group was the focus to eliminate outliers with extended medical leaves), the median usage was 2.1 days.