Socioeconomic Ramifications in the United States

Illness and health have an impact on our lives and communities, and vice versa. COVID-19 is no exception--the ways we gather and interact with one another directly enable transmission of this disease, and steps to mitigate disease spread have ripple effects in our lives. Earlier in this module, you read about the disproportionate impact of the pandemic on communities of color and incarcerated persons, as well as the interventions being undertaken to address housing insecurity. Race, incarceration, and housing are just three of the many social determinants of health, and we encourage you to continue to explore the role of social determinants of health in this pandemic in this section. In particular, we encourage you to consider how infectious diseases and societal responses to them disproportionately impact those experiencing:

• Social isolation

• Housing insecurity

• Incarceration

• Insecure immigration status

• Lack of paid sick leave/ability to take time off from work

• Financial instability

• Lack of childcare and disparities in education in light of school closings

Social Isolation

Social distancing asks us to stay physically separated from one another, posing the risk of increasing social isolation and loneliness (social distancing still allows for other forms of social connection, mostly through technology, that can help decrease social isolation and loneliness). This risk is particularly high for elderly individuals and those already isolated. While the relationship between isolation caused by social distancing and mental health has not been studied prior to the pandemic, this meta-analysis explores the effect of social relationships on morbidity and mortality. Module 4, Mental Health in COVID-19, explores isolation and other mental health impacts of the pandemic.

Social Stigma and Racism

As rates of COVID-19 infection have increased across the United States, so too have racist and xenophobic sentiments toward Chinese and Chinese-American people, or, more broadly, people who appear East Asian. A report from San Francisco State University demonstrated that news coverage of anti-Asian discrimination increased by 50% in February. These reports cited acts against Asian-American individuals and the community at large, as well as xenophobic labels employed by the media and political leaders. Asian-American establishments have seen a particular decline in business. Between January and February, Manhattan’s Chinatown sales dropped between 40-80%, as news of the virus spread in the U.S., even before there were any confirmed cases of COVID-19 in New York City itself. On multiple occasions, President Trump called the virus "The Chinese Virus," despite recommendations from the WHO to avoid geographical descriptors, because prior nomenclature, such as the Middle East Respiratory Syndrome, resulted in stigmatization of particular communities. Amidst these large-scale acts of discrimination, interpersonal attacks have escalated, ranging from accounts of school bullying and verbal harassment to physical assault.‌

Perhaps it is the uncertainty of pandemics or the intangibility of a virus, but scapegoating, as we are seeing with the coronavirus, has historically been common practice in the face of global pandemic. For instance, Europeans blamed Jews for the spread of the Black Death (1348) and North and South Americans blamed those in Mexico for the spread of the Swine Flu (2009). Unfortunately, those of Asian descent have often been the target of the pandemic-related scapegoating. In the mid-19th century, anti-Asian sentiments were on the rise in the United States, especially in California where the highest numbers of Asian immigrants settled. Already relegated to the lower tiers of society, Asian Americans were blamed for the smallpox, malaria, and leprosy that plagued cities like San Francisco. As a result, the United States government enacted overtly anti-Asian legislation in the Chinese Exclusion Act of 1882 which banned the immigration of Chinese laborers to the United States. Eventually repealed in 1943, the Chinese Exclusion Act, among many other anti-Asian actions and sentiments, have perpetuated stigma and “otherness” among the Asian American population. In turn, this population has often become the target of unfounded and unfair treatment secondary to the blame imposed upon this population by the larger population.

Fear may amplify implicit bias, which fuels stigmatizing misconceptions that entire cultural communities are innately more likely to have or spread disease. The CDC affirms that people of Asian heritage are not at greater risk of spreading COVID-19 than other Americans. They recommend educating people on factual evidence and speaking out against discriminatory behaviors. The WHO has cautioned against language that promotes social stigma or attaches locations to the illness. Further guidance from the WHO in preventing social stigma and the spread of inaccurate information can be found here.

Thought Question:

• What role do healthcare workers play in mitigating acts of discrimination?

Insecure Immigration Status

Restrictions on land and air travel to limit viral spread, while necessary from a public health standpoint, have placed significant stress on immigrants, recent migrants, asylum seekers, and those in immigration detention. These populations are at increased risk for COVID exposure and associated socioeconomic hardship as “immigrants on average have less access to safety-net benefits, are more likely to lack health insurance coverage, and have lower median incomes than the U.S. born” (Chisti & Pierce, MPI). Various policies enacted in response to the pandemic, including the CARES Act mentioned above, exclude immigrants and fail to recognize that “every person’s health and financial stability are critical” (ACLU). Additionally, the public charge rule introduced just months before the start of the pandemic has introduced a “chilling effect,” with many eligible families forgoing public benefits such as WIC, SNAP, and housing assistance, which have become all the more necessary with the unique pressures facing immigrant families during the pandemic.

While legislative policies have neglected to protect these populations, many of them find themselves labeled as “essential”, whether they are working within the hospital systems, in the service industry, or in the food industry. Additionally, the essential workforce is greatly supported by DACA (deferred action for childhood arrivals) recipients, for instance upwards of 43,000 DACA recipients work in health care and 76,000 work in the food and service industry. In the face of COVID-19 related anxieties, DACA recipients find themselves concerned about the future of DACA and how renewal offices may be delayed/shut down or the protection they receive may be repealed.

Certain considerations will also need to be made about legal immigration status and visas that are essential to the farm industry -- the Trump administration extended eligibility for H2A visas that allow migrant farmworkers to enter the country each growing season in order to preserve the U.S. food supply. However, these workers have been overlooked in relief packages and remain at increased risk for severe disease due to crowded conditions at work and home, as well as lack of access to medical care. See more here on farmworker visas. Additionally, there have been several efforts to protect those in ICE detention centers, with several legal advocates and judges calling on the detention centers to release residents to mitigate the spread of COVID. Despite these efforts, COVID infection rates inside ICE detention centers continue to rise at a rate greater than that of the general U.S. population. These are some of the myriad issues facing this at risk population in the face of the pandemic, but certainly not a complete picture.

Further Reading

• Perspective piece on undocumented immigrants from NEJM.

• Immigrant Resources Portal

• Undocumented immigrants among the first hit.

• Work done in Chicago to protect this population.

Food Security and Hunger

Lack of income due to job loss, stay at home orders, and “panic buying” have made it difficult for many Americans to find and purchase needed food. Food insecurity has the potential to rise by over 10 million individuals in the coming months, similar to levels seen during the Great Recession. Record numbers of families are relying on food banks and other emergency food resources at the same time that these organizations are seeing fewer donations from the hospitality industry. Food insecurity and social isolation are compounded within communities at the highest risk for COVID-related complications, as food deserts overlap with areas of high unemployment and rates of comorbid conditions. As food insecurity worsens with job losses and economic downturns associated with COVID, it also acts as a risk factor for many of the comorbid conditions associated with increased COVID disease severity, including heart disease and diabetes (see figure). One study found that a third of individuals who lost their jobs during the pandemic reported eating less due to inability to pay for food. Temporary measures to aid low-income families and increase SNAP (formerly known as food stamps) benefits have not been extended, which experts argue could lead to long term health effects of hunger for children and adults. COVID and food insecurity represent a complex interplay of cause and effect, and illustrate one of the many ways social conditions become experienced as health conditions.

Social and Structural Impacts of COVID-19 on Food Insecurity and Health Outcomes

from Leddy et al., 2020

Further Reading

• Feeding Low-Income Children during the Covid-19 Pandemic | NEJM

• Health Justice Strategies To Combat COVID-19: Protecting Vulnerable Communities During A Pandemic

Impact on K-12 Education

Early in the pandemic, schools closed their facilities and switched to virtual learning to avoid transmission of disease. Prior to the pandemic, there were clear disparities in the quality of education in lower income districts nationwide. The closure of in-person school has only furthered these disparities, as students have begun engaging in virtual learning. The etiologies of these disparities have been studied and described well. Schools in poorly resourced settings have less access to technology, making the transition to virtual learning more difficult. In addition, these schools are having to invest more in training their teachers on the inclusion of technology in the classroom, as this type of professional development was not previously made available. For a number of reasons, including disparate access to technology, rates of virtual drop out are high in cities, as one study in Boston showed. For many children, schools serve as an important access point for a variety of services, including physical and behavioral health, nutrition, and developmental services. With physical access to schools cut off, many children are experiencing new barriers to these essential services. Schools where children depend on their school for 1-2 meals everyday quickly set up methods to deliver food to students in the midst of the pandemic. This meant, however, that these already low resourced institutions had even fewer funds to devote to education.

Students who live in well-resourced districts are also likely to benefit from several factors in their home that improve their education. They are more likely to have more books at home, which they can use to supplement their education. They also are more likely to have parents at home who attended higher education themselves and have developed the skills necessary to teach their kids.

Debates over whether to keep schools physically closed or restart in-person learning balance social, behavioral, and educational needs with physical safety and transmission risk. The American Academy of Pediatrics has recommended that the goal of in-person K-12 schooling should be at the forefront of policy plans regarding re-opening, as soon as it is safe to do so. Other experts have recommended prioritization of children in grades K-5 for in-person learning, as well as students with special needs. They acknowledge, however, the differing circumstances and values for communities around the country. Initial reports from virtual learning in the first months of the pandemic have shown mixed results, and come with the warning that long-term educational impacts of the pandemic will not be known for years to come.Educational disparities created and exacerbated by the pandemic will likely have severe ramifications on the education of kids living in low-resourced settings. For more resources to teach kids about COVID-19 at home, please see the COVID-19 Classroom curriculum.

Thought Questions:

• What are some important considerations for designing in-person, virtual, or blended learning plans for schools in your community? Which approach would you recommend, and why?

Impact on Work: Small Businesses, Essential Workers, and Unemployment

Social distancing has become an important strategy for slowing viral spread and flattening the curve. Nevertheless, it has had dramatic impacts for those unable to work from home, as well as businesses that rely on in-person interactions, such as brick and mortar stores, restaurants, museums, and theaters. Early research has shown that nearly half of small businesses have temporarily closed, and large numbers of small business employees have been furloughed or permanently let go. Compounding the current crisis, financial fragility is the norm for these businesses, with many unable to sustain even one month of expenses without their typical cash flow. Many businesses are seeking support through the CARES act and additional loan and grant programs, though many of these are plagued with bureaucratic hoops. This article describes the struggle of food service workers whose work requires them to be public-facing, often without the option for paid sick leave.

Essential workers, including grocery workers, food service workers, public transit drivers, and many more, are exposed to the public on a daily basis, often without the protection they need. In response to lack of protections and continued low wages despite increasingly hazardous working conditions, workers from Instacart, Amazon, and Whole Foods have organized around increased health precautions, hazard pay, and free COVID-19 testing, among other protections. Additional smaller-scale strikes have occurred at restaurants, packaging facilities, and manufacturing plants around the world, often without the structure and protection offered by union representation.

As the pandemic progresses, evidence is emerging that these workers are getting sick and dying at disproportionate rates. Many of these workers also live in “high risk” households, with low household income, uninsured household members, or elderly individuals living at home. With lack of sick leave and low pay rates, these employees often feel forced to continue working to provide for their families, even if they feel unsafe or unwell. Many have called for essential workers to be first to receive a newly-approved COVID vaccine, though this is complicated by varying definitions of who is an essential worker.As the pandemic escalated, unemployment rates in the U.S.have soared. Between March 15 and June 6, over 44.2 million individuals filed for unemployment, reaching a peak of 6.9 million claims in one week on March 28, nearly ten times the previous record. Updated data released December 4 by the Bureau of Labor Statistics confirmed that the unemployment rate has reached 6.7%, improving from May 8’s estimate of 14.7%, which was higher than it had been since the Great Depression. The increase in unemployment claims has overwhelmed the system, leading to long waits on the phone, crashing websites, and, ultimately, delays in accessing essential benefits. Notably, though other countries have implemented similarly restrictive social distancing policies, they have not triggered similar massive unemployment claims. Instead, many countries have enacted policies that require employers to pay a certain percentage of an employee’s salary during this time and guarantee employment once the pandemic has passed. How quickly and effectively a nation’s economy recovers from this pandemic may rely on creative strategies implemented now.

Further Reading:

• Details and loopholes on paid sick leave as proposed in Families First bill: Paid sick leave: Who gets it during the coronavirus outbreak

• Grocery shopping and risks to grocery store workers: Coronavirus Panic Buying Puts Grocery Workers and Shoppers at Risk of Infection

• Which workers are most at risk? The Workers Who Face the Greatest Coronavirus Risk

• Essential Workers and Reopening: Listen To Essential Workers First. Then, We Can Consider Reopening The Economy

Economic Implications of the Pandemic

The economic effects of the pandemic are many and will likely continue to become evident in months and years to come. It is probable that we will enter a recession, and unlike some prior recessions, this one is abrupt and global. Some overarching themes to understand these effects include a decrease in labor, supply chain disruptions, and a decrease in demand for many consumer goods.

First, there is certainly a decrease in labor. This decrease in labor is exacerbated by poor working conditions, limited worker protection, and decreased compensation, prompting worker strikes as outlined above. Many production centers work at a stable basal rate and are not equipped to operate under conditions that result from a surge in demand, such as that for medical masks. In order to accommodate an increase in demand for one good and a decrease in demand for another, some production centers are able to contribute to the dwindling supply by modifying their efforts, however, this modification is more feasible if the demanded good is easier to produce. Consider distilleries modifying their production lines to produce hand sanitizer, a manufacturing adjustment that is much easier to accommodate than the demand for ventilators, which requires more specialized production.

This issue highlights another shock introduced -- a precipitous decline in demand for many goods, meaning production must halt entirely and, at times, results in the wasting of goods. Decreases in travel and tourism are revealing balances that exist within the supply-demand chain as a result of global interconnectedness (for more details, see the OECD report).

Some have proposed that disruption to the global food system will be the third shock our world experiences from the pandemic, with supply-demand mismatch and resultant hunger possible worldwide. While supermarket sales have increased, demand from restaurants and schools has steeply declined, a shift felt particularly by the seafood industry. Inability to quickly change packaging and distribution practices on US farms has resulted in wasting large volumes of food, all while food insecurity increases. Agriculture and the food industry are not exempt from the same labor shortages experienced in other sectors of the economy, and many workers within the food system face poor working conditions, as described above. Their absence from work not only decreases the availability of food products, but also increases the workers’ own likelihood of becoming food insecure.

The World Bank is working to maintain import/export agreements that typically create stability within the global food market, but this has been complicated by countries that rely on income from other commodities, such as oil, to purchase and import food. Faced with less demand for these other commodities, these countries are less able to import the food they need. While large-scale global supply chains risk disruption, small scale farmers around the world will also lose access to their regular markets. Both large and small scale agriculture and food production take place in predominantly rural settings globally, leaving rural economies with the brunt of this economic burden. In many rural communities in the Horn of Africa, the Middle East, and South Asia, farmers are also facing one of the worst locust resurgences in years. Around the world, hunger and alteration in food supply have the potential to impact a number of health problems not otherwise directly related to COVID-19, including nutritional deficiency, growth and development problems, and metabolic diseases such as diabetes.

Structural and political mismanagement of the situation can worsen an economic downturn. These and other economic principles, in addition to GDP trends during other pandemics in history, are reviewed here.

Some economists have called for increased guidance from the federal government in directing industry to produce supplies, as well as a more consolidated response unifying economic and public health responses. Initially, many analyses put these two realms in opposition to one another, implying that either public health or a robust economy must be sacrificed at the others’ expense. However, a panel of top economists overwhelmingly disagrees with this dichotomy, supporting public health measures as tools for economic recovery. A letter to the editor challenges policy makers to think outside of this dichotomy, suggesting that we pursue aggressive testing and precautions that allow our economy and world to return to normal more quickly.

Further Reading:

• 5 of the World's Smartest Economists Share Ideas on Saving the Economy

• Response to current debate weighing economic consequences of continuing social distancing: Can We Put a Pricetag on Life? The Shutdown Forces a New Look

• Deep dive into the macroeconomics of epidemics

• Read more about the UN plan to prevent a global food crisis here

Thought Questions:

• What is the role of the federal government in public health and economic responses to COVID?

• How can public health and economic responses work synergistically?

• The pandemic has been described as a global phenomenon that has exposed the “Achilles’ heel” of many social and structural shortcomings. What shortcomings have you identified during this pandemic and, if given the chance, how would you propose we address them after the pandemic ends?