SARS-CoV-2, the virus responsible for Covid-19, is not an equal opportunity killer. That the burden of disease, even novel diseases like Covid-19, is distributed unequally according to social rank is a central finding of the scholarly discipline of social epidemiology, built on nineteenth-century scholarship by Friedrich Engels, Louis-René Villermé and Rudolf Virchow. It is heartening that journalists, policymakers, and medical professionals have become sensitized over the last few weeks to the strikingly disparate Covid-19 outcomes across race, ethnicity, and class. However, less attention has been paid to the fact that social inequality makes the pandemic more severe, not only for the most vulnerable, but for all of us. It’s worth thinking clearly about why that is so. I outline three main mechanisms: First, inequality makes it more likely that the people who get the virus will spread it—and while people at the bottom of the social hierarchy are more likely to get it, everyone is at some risk. Second, social inequality makes the load on health systems at the peak of pandemic waves higher than it would be in a more equal society, which places anyone who needs hospitalization for any reason at greater risk. Third, social inequality creates pressure to lift social distancing restrictions too quickly, which puts all of us at risk of second and subsequent waves.
We won’t be sure until we have access to more complete and cross-nationally comparable data, but given what we know about the social determinants of health more broadly, it seems safe to conclude that social inequality has very likely increased the rate of spread of SARS-CoV-2 in the first wave of the Covid-19 pandemic in the United States. This is because social inequality affects the distribution of epidemiologic risks and protective factors in ways that make the novel coronavirus more likely to spread.
“A lack of protective social policies made staying home from work in order to avoid infection impossible for many lower-wage workers.”For example, early in the pandemic, people with limited access to high-quality health information were less informed about the need for social distancing and handwashing. As it spread, lower incomes made it more difficult to avoid social contact by ordering delivery of groceries or staying home from work. A lack of protective social policies made staying home from work in order to avoid infection impossible for many lower-wage workers. Members of racial and ethnic minorities are highly concentrated in the essential jobs with most limited access to personal protective equipment—e.g., public transportation, meat packing, and the lower rungs of the healthcare sector—further exposing them to the risk of infection. Decades of stagnant investment in public housing and transportation have also increased the likelihood that people of lower socioeconomic status living in major cities will live and travel to work in crowded conditions, leading to still greater exposure. All of these differential exposures mean that people of lower socioeconomic status—i.e., those who belong to stigmatized minority groups, have low incomes and wealth, low levels of education, and work in low-status occupations—have borne the brunt of exposure to the virus.
Social inequality also structures the prevalence of preexisting conditions which increase the severity of illness from SARS-CoV-2. The stresses of poverty and racism, occupational hazards, living in areas with higher levels of particulate air pollution, and lack of timely access to affordable medical care are all associated not only with lower socioeconomic status, but also with conditions such as diabetes, cardiovascular disease, and chronic pulmonary disease that worsen the course of Covid-19.1For example, see Amir Emami et al., “Prevalence of Underlying Diseases in Hospitalized Patients with Covid-19: A Systematic Review and Meta-Analysis,” Archives of Academic Emergency Medicine 8, no. 1 (2020): e35.; Eric B. Brandt et al., “Air Pollution, Racial Disparities, and Covid-19 Mortality,” Allergy and Clinical Immunology, May 7, 2020; and Javier Valero-Elizondo et al., “Persistent Socioeconomic Disparities in Cardiovascular Risk Factors and Health in the United States: Medical Expenditure Panel Survey 2002–2013,”Atherosclerosis 269 (2018): 301–305. Those who are most severely affected by the disease carry higher viral loads, shed more virus, and are hence more likely to infect those with whom they come into contact. They are also those who are least able to social distance, stay home from work, and avoid communicating the disease to others. In this way, social inequality has led to a faster spread and a higher peak of the pandemic than would be expected in a more equal society.
Social inequality worsens Covid-19
Even before the first wave of the pandemic had begun to flatten and subside in the United States, pressure to reopen the economy was mounting. Of course, some degree of reopening makes sense. As we reinforce our healthcare systems and learn more about how the virus does and does not spread, as well as who has already acquired immunity, it is becoming possible to identify economic and social activities that present minimal risk. But reopening economic activity too quickly increases the risk and severity of subsequent waves, and pressure to do so is intensified by high levels of inequality.
One source of pressure to reopen is the dire financial circumstances affecting those whose livelihoods have been hit by the pandemic. In a survey conducted in late April by the Pew Research Center, more than half of adults living in households with incomes below two thirds of the median reported that someone in their household had lost a job or taken a pay cut due to the coronavirus outbreak. But less than a quarter of adults in this income range reported having savings sufficient to cover their expenses for three months in case of an emergency.
“In the absence of universal, comprehensive insurance against job and income losses, most Americans will be unable to survive a long-term shutdown of the economy.”Stimulus checks issued to taxpayers will buffer the impact of the economic shutdown for many families, but a one-time payment of $1,200 will not be a long-term replacement for lost jobs and wages. Meanwhile, weak administrative systems and restrictive rules in many states mean that of the more than 44 million Americans who have filed for unemployment benefits since the beginning of March 2020, and a study released in May showed almost half had yet to receive benefits. In the absence of universal, comprehensive insurance against job and income losses, most Americans will be unable to survive a long-term shutdown of the economy.
The large number of families that cannot afford to remain out of work with only the meager public supports available to them will inevitably create pressure to reopen the economy—not only those sectors of the economy that can safely begin to operate with social distancing, but also those services such as schools and child care where such distancing is far more difficult and which will also need to reopen if adults with children are to return to work. Recurrent waves of infection generally occur in pandemics similar to the novel coronavirus outbreak; they are likely to be steeper and closer together as a result of the intense pressure to reopen that our unequal economy generates.
The political consequences of gross inequality are also likely to provide fodder for a too-hasty and inadequately supported reopening of the economy. Socioeconomic inequality translates into political inequality: People of lower socioeconomic status participate in politics at lower rates (and are even further underrepresented in politics because of their higher rates of incarceration and death).2David Cottrell et al., “Mortality, Incarceration, and African American Disenfranchisement in the Contemporary United States,” American Politics Research 47, no. 2 (2019): 195–237. Furthermore, political elites are less responsive to the policy preferences of constituents with lower socioeconomic status than to those of economic elites.3See Martin Gilens, Affluence and Influence: Economic Inequality and Political Power in America (Princeton, NJ: Princeton University Press, 2012). Outside of the electoral arena, the preferences of the superrich and business elites are even more thoroughly reflected in US policy, not least because of a decades-long strategy of reducing the influence of working-class people by undermining organized labor.
To the extent that socioeconomic elites prefer a faster reopening of the economy, their unequal influence in politics is likely to hasten a second wave of the pandemic. The concentration of resources at the top of the social hierarchy leads to hoarding behavior in highly unequal societies, as those at the top of the hierarchy seek to protect their social and economic privileges—including the privileges of resuming prepandemic patterns of business, consumption, and social life—despite risks to workers.
“Enlightened political and economic elites may recognize that reopening the economy prematurely will do more harm than good.”Enlightened political and economic elites may recognize that reopening the economy prematurely will do more harm than good. But when schools, neighborhoods, and social worlds are segregated by race and class, it becomes more difficult for the powerful to imagine that they share a common fate with the “lower” social orders. Consider, for example, Wisconsin Supreme Court justice Patience Roggensack’s comment during a hearing of a lawsuit brought by the Wisconsin Republican legislators against Governor Tony Evers’ stay-at-home order. Roggensack appeared to downplay the seriousness of a coronavirus outbreak among meatpacking workers on the grounds that it didn’t affect “the regular folks in Brown County.”
Mitigating social inequality and Covid-19
What, if anything, can we do at this point to break the cycle of inequality, infection, shutdown, and premature reopening? First, robust income support policies that allow people who are infected or at risk of infection to stay home from work without fearing loss of livelihood are essential. Given both the political benefits of universal social policies and the underfunded, overstretched information systems on which most government transfer programs are currently running, access to income replacement should be made unconditional, rather than means-tested or subject to proof of medical condition.
Second, the people whose labor keeps society going—both as “essential workers” during waves of active pandemic and those who must work in the early stages of economic reopening—must be supplied at no cost with effective personal protective equipment. No bus driver, sanitation worker, grocery store clerk, nursing home aide, meat packer, hospital orderly, or teacher should be sent to work without a face shield and daily supplies of N-95 masks, gloves, and hand sanitizer.
“Policies that stimulate job creation and promote wage growth for low- and middle-income workers will not only boost the economic recovery, but also make recurrent waves of the pandemic less severe.”Third, after decades of declining returns to labor, we urgently need macroeconomic and labor market policies that will equalize how the benefits of economic activity are distributed. Policies that stimulate job creation and promote wage growth for low- and middle-income workers will not only boost the economic recovery, but also make recurrent waves of the pandemic less severe. That is because well-paid workers with job security are less prone to the preexisting conditions that make them vulnerable to Covid-19, and are better able to weather time off work without pressuring for premature reopening. More equal distribution of income will also, over the long run, help to correct some of the political imbalances that have contributed to the uncontrolled growth of economic inequality and create a sense of linked fate as Americans that is critical for effective pandemic response.
