Introduction: The COVID-19 Shock to Our Deep Inequities: How to Mitigate the Impact

A Guide to the Articles

The first set of articles focuses on economic and sociodemographic issues and inequities; the second set focuses on demographic and geographic diversity in public health and mortality outcomes; and the third set focuses on specific issues, such as the underlying conditions that resulted in devastating outcomes in nursing homes and the implications of structural racism in specific industries.

In their article, Jonathan Rothwell and Ember Smith provide an empirical summary of the relationship between socioeconomic status and the economic and disease burden of the COVID-19 pandemic. They examine how well income, education, race, and ethnicity predict disproportionate risk of layoff, income loss, infection, and death related to the virus at the individual level and small geographic unit level across the United States.

To study the disease burden and investigate the relationship between COVID-19 infection and death risk, they relied on large-scale Center for Medicaid and Medicare Services data, Census Household Pulse Survey data, and a zip code database constructed from disparate public records. They also studied economic effects using data from the Bureau of Labor Statistics and Household Pulse data. They find that low socioeconomic status is strongly related to higher risk of physical harm (100–200 percent greater) and economic harm (30–100 percent greater) related to the pandemic. Education and income have similar effect sizes as racial and ethnic disparities, with American Indian, Black, and Hispanic Americans facing consistently worse outcomes.

To shed light on potential mechanisms, Rothwell and Smith use Gallup survey data and other sources to investigate how disease-prevention measures relate to socioeconomic status. They show that disparities across socioeconomic status do not appear to be linked to preventive behaviors—such as social distancing and mask use, which are no lower and sometimes higher in lower-socioeconomic-status individuals—but do appear to be linked to occupation- or industry-related exposure that put lower-socioeconomic-status households at higher risk of disease or layoff.

In a related article, Bradley Hardy, Charles Hokayem, and Stephen Roll explore the disruption that COVID-19 caused to public health and the economy, including the loss of more than half a million lives and millions of jobs. The burden of this pandemic was not shouldered equally by American families. Black and Hispanic communities were hit the hardest, resulting in an exacerbation of already existing disparities. Using nationally representative data, they document the employment response to COVID-19 by race and ethnicity. Within these groups, they also explore differences by education and industry. They find higher levels of employment loss among Blacks and Hispanics, those without college degrees, and frontline workers; as well as evidence that individuals and families faced serious mental health episodes and turned to costly alternative financial strategies to cope throughout the crisis.

Building on this discussion, Michal Grinstein-Weiss, Yung Chun, Stephen Roll, and Jason Jabbari draw on data from the first two waves of the longitudinal Socio-Economic Impacts of COVID-19 Survey to show how racial and ethnic disparities in savings and job loss during COVID-19 explain disparities in housing hardships, as well as the extent to which the federal government’s Economic Impact Payments moderated this relationship. Using a structural equation modeling approach—which allows for the simultaneous exploration of the relationships between race/ethnicity, household hardships, and liquid assets, and the receipt of the Economic Impact Payments—they find that liquid assets significantly mediated the relationship between race/ethnicity and housing hardships, and that this effect was stronger for those who lost jobs or incomes as a result of COVID-19.

In examining the relationship between race and ethnicity, liquid assets, and household hardship, as well as the efficacy of public supports in helping households avoid hardship, their article speaks directly to several of the intersecting risks and consequences of the COVID-19 pandemic. Furthermore, by documenting both the disparate impacts of the pandemic in conjunction with potential policy tools to help address these impacts (liquid asset supports, public payments), the authors’ research can directly inform future efforts to make the population more financially resilient to large economic shocks.

In their article, Emily Dobson, Carol Graham, and Ethan Dodd highlight how divided the United States was in terms of opportunity, health care, and optimism even before COVID-19 landed. This was reflected in the preexisting crisis of deaths of despair—suicides, drug overdoses, alcohol disease, and other preventable deaths primarily among less-than-college-educated middle-aged whites. That crisis claimed more than one million lives in the decade prior to COVID and was then severely exacerbated by COVID.

The authors explore the places and populations that were most vulnerable to COVID deaths and where they coincided with vulnerability to high levels of deaths of despair. They also used metrics of well-being to explore COVID’s spillover effects—uncertainty, high levels of unemployment, and social isolation, among other things—on vulnerable populations. Their earlier research found that these metrics, particularly lack of hope and worry, track with the patterns in deaths of despair, with minorities much more optimistic and less represented in these deaths than whites. Here they explore how these trends changed with COVID, using summary EMS first responder data on opioid overdose rates and mental/behavioral reports to compare March through July 2020 to the same periods for 2018 and 2019, to assess excess deaths attributable to the onset and spread of the pandemic.

Finally, the authors analyzed the stark changes in well-being, based on the data from the first two waves of the longitudinal Socio-Economic Impacts of COVID-19 Survey implemented by the Social Policy Institute at Washington University in St. Louis, where Graham is associated faculty. Remarkably, the cohorts with the highest COVID death rates—low-income African Americans—still report more optimism and better mental health than other race/income cohorts, although they did experience increases in anxiety at the same time. These findings again highlight the complex intersections of risk and resilience at play as the virus spread through a highly unequal public health system and society.

Shannon Monnat investigates rural-urban continuum differences in COVID-19 experiences. These differences include impacts to physical and mental health, social relationships, employment, and financial hardship among U.S. working-age adults (ages 18–64) using timely and novel survey data collected in February and March 2021 (N = 3,933).

Most respondents (58 percent) reported that COVID-19 has had a negative impact on their lives. Residents of rural counties that are adjacent to metro areas reported the worst outcomes. They were more likely than their large urban peers to report testing positive for coronavirus; living with someone who tested positive; having a close friend or family member outside of the household test positive; having a close friend or family member hospitalized; seeking treatment for anxiety or depression; meeting the clinical threshold for anxiety; reporting that their relationships with friends and immediate family worsened; working fewer hours than normal; being late paying rent, mortgage, and other bills; not being able to afford groceries or other necessities; and getting a loan from family or friends.

Residents of remote rural counties also generally reported worse outcomes than large urban residents, but differences were no longer statistically significant after introducing covariates. The findings reinforce the fact that rural areas are not homogenous and that some have experienced worse outcomes than others during the COVID-19 pandemic. Monnat emphasizes how recovery policies must consider geographic variation in COVID-19 vulnerability and impacts, among many other challenges.

Brian McGarry and David Grabowski focus on the staggering amount of death and suffering the COVID pandemic caused in U.S. nursing homes. The spread of the virus across the country introduced a new emergency to a long-term care sector that had been in a state of crisis for multiple decades. Nursing homes have been underfunded and understaffed for years, delivering inadequate care to their vulnerable residents that is often sterile and overinstitutionalized, yet detached from the resources of the rest of the U.S. health care system. During the pandemic, policy responses at both the federal and state levels were often slow and inadequate, partly because of a frayed infrastructure due to years of inattention from policy-makers.

The authors stress that beyond ensuring the viability of nursing homes for the foreseeable future, a package of broader policy and delivery reforms should be implemented to improve the care of older adults and help to prevent future tragedy. Yet again the pandemic exposed deep structural weaknesses in our systems of care and has presented us with difficult but important challenges to address.

The penultimate article, authored by Terri Friedline, Anna Wood, Mikal Wheatley, Seyoung Oh, and Haotian Zheng, focuses on structural racism. The article highlights how the COVID-19-induced recession revealed examples of systematic discrimination within a wide range of industries, including banking. Using data from interviews conducted with bank employees in March and April 2020, the authors explore how private banks exemplify racialized organizations and operate within the broader economic system of racial capitalism that prioritizes pursuit of profits over the interests of their customers.

They show how the banking industry’s responses to the pandemic reflect the logic of racial capitalism and develop the theme of doubling down to illustrate the logic and to explain the patterns revealed in various employees’ narratives. Subthemes in the article include pursuit of profits; bureaucratic mundane, forced choices; history limits imagination; and dissonance. The authors conclude with the implications for the banking industry, but also for other industries in which structural racism is prominent. The findings and the conclusions of the article highlight the intersected nature of our economic and social inequalities and how those were exacerbated by the COVID pandemic and its disastrous economic spillover effects.

This brief introduction cannot do justice to the depth and breadth of the analyses in the articles in this volume. We believe that the set of articles is, in turn, greater than the sum of its parts, and can potentially play an important role by both identifying the wide range of inequities in our economic, health, and social safety net structures; and proposing potentially feasible solutions for addressing and mitigating these inequities. Edward Lawlor identifies some of these, as well as some broader themes that emerge, in his conclusion to the volume. We hope that this volume and the issues that it highlights will spark a focused public debate and provide the empirical and theoretical basis for future research in these areas.