Viruses aren’t picky. They tear through neighborhoods and nations, infecting whomever they can, and the new coronavirus is no exception: The pain of the present pandemic will be felt—is already being felt—by just about everyone in the United States and all over the world, in one way or another. After the pandemic has run its course, no one will be wholly untouched.
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At the same time, there will be stark disparities in how certain segments of the American population experience this crisis. Some of these disparities will be the result of luck or coincidence—a matter of where someone happened to travel, what line of work they chose, or what city they live in. But in a country that was highly unequal in so many ways well before it had a confirmed case of COVID-19, other disparities will be sadly predictable, falling along racial and class lines, as well as other fateful divides.
In the coming months and years, there will really be two pandemics in America. One will be disruptive and frightening to its victims, but thanks to their existing advantages and lucky near misses with the virus, they will likely emerge from it relatively stable—physically, psychologically, and financially. The other pandemic, though, will devastate those who survive it, leaving lasting scars and altering life courses.
Which of these two pandemics any given American will experience will be determined by a morbid mix of a sort of demographic predestination—shaped strongly by inequality—and purely random chance.
When someone dies, there are three ways to think about what caused it, according to Scott Frank, a professor at Case Western Reserve University’s School of Medicine. The first is the straightforward, “medical” cause of death—diagnosable things like heart disease or cancer. The second is the “actual” cause of death—that is, the habits and behaviors that over time contributed to the medical cause of death, such as smoking cigarettes or being physically inactive. The third is what Frank refers to as the “actual actual” cause of death—the bigger, society-wide forces that shaped those habits and behaviors.
In one analysis of deaths in the U.S. resulting from “social factors” (Frank’s “actual actual” causes), the top culprits were poverty, low levels of education, and racial segregation. “Each of these has been demonstrated to have independent effects on chronic-disease mortality and morbidity,” Frank said. (Morbidity refers to whether someone has a certain disease.) He expects that the same patterns will hold for COVID-19.
To begin with, the physical effects of COVID-19 are far worse for some people than others. There are two traits that seem to matter most.
The first is age. Older people are at greater risk of experiencing the more devastating version of the pandemic, in part because the immune system weakens with age. Early data from the Centers for Disease Control and Prevention indicate that, in the U.S., the risk of dying from the disease begins to climb at around age 55, and is especially acute for those 85 and older. “I think the pattern we’re going to see clearly is an age-related pattern” of mortality, Andrew Noymer, a public-health professor at UC Irvine, said. (Younger people aren’t invulnerable to the disease, though; the CDC found in mid-March that 20-to-54-year-olds had accounted for almost 40 percent of hospitalizations known to have been caused by the disease.)
The second trait that puts someone at increased risk is having a serious health condition such as diabetes, heart disease, or lung disease. These conditions seem to make cases of COVID-19 more likely to be severe or fatal, and the risks rise considerably for older adults who have any of these conditions, Frank told me.
But while everyone ages, rich and poor alike, these health conditions are not evenly distributed throughout the population. They’re more common among people with less education, less money, and less access to health care. “We know these social and economic conditions have a profound effect on chronic disease,” Frank said, “and then chronic disease has a profound effect on the mortality related to COVID.”
When we someday tally up all the casualties of the coronavirus, the high number of older Americans among the dead will reflect the sad, universal fact of physical decline. But for many of those who had underlying health conditions, inequality will be the actual actual cause of death.
Since some minority groups have a higher prevalence of certain health conditions, like diabetes or high blood pressure, COVID-19 will likely affect them more intensely. “We may not see it now, but when we look back at who was the sickest, who had the most complications, where there were excess deaths, it’s likely that we might see those coming down along racial lines,” Hedwig Lee, a sociologist at Washington University in St. Louis, told me in mid-March.
This pattern is already starting to emerge in early data from places that include information about race in their reports on the local impact of the virus. In Chicago, where less than one-third of the population is black, more than two-thirds of the 86 people killed by COVID-19 as of last weekend were black—and four in five of those black patients had high blood pressure and/or diabetes. The state of Michigan and the Wisconsin county that contains Milwaukee have also had a disproportionate number of black residents die from the disease. A similar pattern was borne out in a recent CDC cross-country snapshot of hospitalizations in parts of 14 states during the month of March; black people accounted for 33 percent of hospitalizations for which racial data was available, despite making up only 18 percent of the population in the areas surveyed.
Lower-income people, in addition to any other risk factors they may have, are also at increased risk because their finances might change the way they seek treatment for the disease if they come down with it. When lower-income people get sick, “they oftentimes delay going to the doctor, not because they don’t want to get well, but because they simply don’t have the money,” Rashawn Ray, a fellow at the Brookings Institution, said. “They wait until the last minute to go get help, like when they are literally about to die or when something catastrophic is happening.” And forgoing a doctor’s guidance until the late stages of an illness—COVID-19 or not—could be especially dangerous during a pandemic.
Americans’ health varies along racial and economic lines in the best of times. That will probably make the outcomes just as uneven, if not more, in the worst of times.
Two important predictors of an American’s well-being right now, other than whether that person has COVID-19, are the answers they and others in their household would give to two questions: Are you still able to work? And if so, can you work without risking exposure to the virus?
For a rapidly growing portion of the country, the answer to the first question is no. Three weeks ago, some 3.3 million Americans filed for unemployment benefits in a single week, a record-breaking total that was nearly five times as large as the previous recorded high. The following week, the number of new claims was twice as high—6.9 million. Still another 6.6 million claims were filed last week, bringing the recent three-week total to nearly 17 million—an enormous figure that likely still understates how many Americans are actually out of work right now.
While few sectors of the economy have been spared by the pandemic, the businesses that have so far been hit particularly hard are the ones premised on physical presence and face-to-face interactions, such as retail stores, restaurants and bars, and hotels. “If we think about those industries, they have a lot of low-wage and part-time workers,” many of whom live paycheck to paycheck, said Susan Houseman, the director of research for the nonprofit Upjohn Institute for Employment Research. “We worry about them in every single recession, and here they’re just being slammed.”
In this realm, too, racial minorities tend to be more vulnerable. Houseman noted that African American and Hispanic workers are usually disproportionately likely to lose their job during downturns. That was true during the Great Recession, and so far appears to be true of this economic crisis: According to the Pew Research Center, as of late March, 29 percent of white Americans said someone in their household was out of work or had received a pay cut because of the pandemic, while 36 percent of black Americans and 49 percent of Hispanic Americans said the same. (Separately, a recent study also suggested that women may be more likely to lose their job than men.)
Of course, still having a job is not an unalloyed good; for much of America’s current workforce, earning a paycheck means exposing oneself to the virus. There is a portion of the population, though, who are able to safely work without going outside and risking infection. For them, this period is generally more bearable. The Bureau of Labor Statistics estimates that less than 30 percent of American workers are able to do their jobs from home, and finds that this is much more likely to be the case for people who have at least a bachelor’s degree. Remote workers’ relative safety may persist even once life starts returning to normal, if people who are able to work from home choose to continue to do so, out of caution.
But because of the nature of the pandemic, the danger of a job doesn’t map entirely neatly onto income and education levels. Yes, it’s the case that many truck drivers, grocery-store workers, and delivery people are still out in the world and risking exposure to the virus, but so are doctors, nurses, and pharmacists. The industry in which one happens to work is another point at which class and chance intersect.
During milder economic downturns, people who lose their job may be able to find work in another industry. But because such a wide range of businesses have scaled back or shut down operations, job hopping is harder to pull off now, Houseman said. It's also riskier: Grocery stores and delivery companies are hiring ambitiously, but for jobs that will put workers in greater danger of viral exposure.
The answers to each of these two questions—whether someone still has a job, and whether they can do it safely—strongly predict how any given American household is faring right now. To illustrate this, Rashawn Ray, the Brookings fellow, talked me through the probable realities of people who can do their job from home and people who are currently out of work.
The former group is likely to be salaried, and can limit their trips outside the house. They may have children to look after and stress over, but, barring any health concerns, they’re doing fine. “Their job is safe, their salary and wages are safe, their mortgage and house is safe … and they’re able to go to the grocery store and load up on a whole bunch of groceries,” Ray said. Maybe they even choose to have the groceries delivered.
The latter group “is living a completely different life right now,” Ray told me. Perhaps they were already living paycheck to paycheck, but now that they’ve been laid off or furloughed, they’re not sure how they’ll be able to pay their usual expenses, let alone stock up on food and supplies. “A lot of people who don’t have money coming into the household are worried about losing their apartment or house, they’re worried about the fact that they can’t get access easily to the food they need, and now they’re sitting at home with families, with children, trying to figure out what’s happening,” Ray said.
Andrew Noymer, the public-health professor, put it more concisely: “Someone is at home wondering how he’s going to make rent and feed his family,” he said. “And someone else is wondering if they can binge-watch the first season of The Sopranos or whatever.”
The uncertain duration of this period makes getting through it even more difficult. “I think that even a month of this could have devastating effects for many of our most vulnerable” people, said Beth Mattingly, an assistant vice president in regional and community outreach at the Federal Reserve Bank of Boston. “The longer it goes, the more concerned I am, and probably my concern grows exponentially, not linearly.”
Whenever it does end, Ray’s first group will likely have a relatively smooth transition back into the office: They’ll throw their laptops into their bags, drop their kids off at school or daycare, and resume whatever projects they were working on the previous day from home.
But the second group probably won’t be able to get back to work so quickly. Houseman likened the post-pandemic bout of rehiring to “a game of musical chairs,” because many businesses could go under between now and then. “Some will start hiring again, but there will be more workers for the jobs they have than they can hire,” she said. “The longer [closures] persist, the more businesses are likely to go bankrupt, and the slower the recovery will be.”
One thing that can provide a buffer from labor-market turbulence is having savings to draw on. No amount of cash can grant someone immunity from the virus itself, but wealth can prevent the pandemic from leaving deep financial scars. “If you think about the possibility that people have to declare bankruptcy or foreclose on their house or lose their car, that takes a long time to recover from,” said Vida Maralani, a sociologist at Cornell University who studies inequality. “If you have to use up all your wealth, that’s really different than ‘Gee, I lost the money [I put down] on a summer Airbnb and now I can’t vacation.’”
Life in America is always hard without cash reserves, but it’s especially hard now. One 33-year-old woman in a small town in Texas told a New York Times reporter, “I’m not going to let my kids go hungry. If I have to just eat once a day, that’s what I have to do.” She’s disabled and doesn’t work, and her husband, a carpenter, has had fewer jobs lately.
According to the Federal Reserve, just under 40 percent of American adults wouldn’t have enough cash on hand to cover an unexpected $400 expense, and that was before the pandemic cut off so many workers’ earnings. Having even a few thousand dollars saved up can make this time less stressful, Maralani said. It can be the difference between being able to cover a couple months’ expenses, like rent or car payments, and wondering where the money for them will possibly come from.
The federal government is attempting to address household-budget shortfalls. Late last month, Congress passed and President Donald Trump signed a $2.2 trillion economic relief package that included $300 billion to go directly to American households. Most adults will get $1,200 each, plus $500 per child (though they may not receive it until weeks or months from now). Beth Mattingly, of the Boston Fed, told me she thinks the relief package will “provide significant help,” though “those who become unemployed or see their work hours reduced may still need more assistance.”
Even if Americans receive help from the government, Rashawn Ray foresees lasting financial consequences for people who aren’t able to pay their bills now. “If they are in a position where they have taken on a sizable amount of debt, [maybe] through payday loans, now they have added economic stressors that they’ll have to deal with,” he said. Additionally, even if landlords or lenders allow people to delay their rent or mortgage payments, that doesn’t mean those people won’t have to make those payments eventually. “If this lasts 90 days, that’s three months of rent they have to make up,” Ray said.
And in households across the country, regardless of wealth and income, COVID-19 will kill now-unknown numbers of people who support their families financially, Houseman noted. Their deaths will be painful personal losses for their families, who will also suffer economic consequences.
But in keeping with the often dystopian nature of American inequality, some households may, amid the tragedy, come out ahead. “I think there are also going to be some people who are saving money in this,” Mattingly said. “Their income hasn’t changed, but they aren’t going out to eat, they’re not driving, they’re not going to work in the office.” They may not emerge from the pandemic completely unscathed, but they will have a much easier time transitioning back to normal once the crisis wanes.
As health-care workers confront the coronavirus on the front lines of hospitals, the home front of this pandemic is literally the home. That’s where many Americans are dutifully spending their days, and the conditions and location of one’s housing have significant bearing on how one weathers a pandemic. Living in a cramped apartment with lots of relatives is risky on top of being uncomfortable; sharing a spacious, well-appointed house with few other people makes it safer and easier to ride out a lockdown.
In fact, some people may be thinking to themselves, as they hunker down with their work laptops, Netflix queues, and lack of social commitments, that pandemics aren’t so bad. Those people likely don’t have serious health conditions or jobs that require them to leave home. They probably also don’t have small children. For parents with kids at home, “you suddenly have a very different act to juggle than you had before,” Vida Maralani, the Cornell sociologist, said. Many parents who are able to work from home, especially mothers, are stretched as they try to do their jobs while looking after their children all day. Meanwhile, many parents who are struggling to make ends meet have those same child-care responsibilities on top of the stress of continuing to work outside of the house, out of necessity.
Kids themselves will experience the pains of the pandemic unevenly, as keeping children out of school for several weeks or months may widen existing educational disparities. Many students from lower-income households simply aren’t logging on for their school’s online classes to begin with, sometimes because they don’t have a good internet connection at home. Maralani speculates that children whose parents have more time and resources may receive more and better home instruction than their peers, which may produce short-term or possibly even long-term learning gaps. Those are likely the same children who, even in the absence of their school’s usual art or music programs, are still attending their violin lessons or karate classes over videochat.
The stress of managing a home can increase when older relatives are present. According to the latest data from the Pew Research Center, 20 percent of Americans live in households with two or more adult generations or with grandparents and grandchildren; Asian, Hispanic, and black Americans are more likely to live in multigenerational households than white ones.
This household arrangement is especially fraught in a pandemic, when every present body is another potential distributor, or recipient, of the virus. In February, a research team led by the World Health Organization estimated that transmission between people living in the same household was responsible for 78 to 85 percent of some 350 clusters of infections in two provinces in China. This is concerning for larger households around the world, and additionally so when they include older relatives, who tend to be at higher risk.
American families, whether big or small, are riding out this pandemic with varying degrees of comfort. As my colleague Megan Garber recently noted, the unpleasantness of staying indoors is related to “how much room you have, how many rooms you have, whether you have a dishwasher or a washing machine or internet, whether you have an area in which to exercise or be alone or be together or cook or get fresh air.” The distinguishing features of a living space, Garber argued, take on magnified importance when its occupants are there more or less around the clock.
The physical spaces where people are enduring lockdown capture the full range of American inequality. Some affluent urbanites, finding their primary residences dissatisfactory, have retreated to their vacation homes; at least one billionaire has been sheltering in place in the Caribbean on his yacht. Meanwhile, some people without a place to live recently gathered in a makeshift shelter in a parking lot in Las Vegas without walls or a roof; across the country, groups that provide support to people without a home are scaling back or shutting down their operations, for fear of spreading the disease. “I do worry about them,” Andrew Noymer said of homeless people, noting that the virus could spread quickly among those who live in close proximity to one another. Prisons and jails, too, seem to be tragically conducive to the spread of disease.
Beyond the four walls (or no walls) of any particular living space, some neighborhoods will probably be more vulnerable to the virus than others. “Communities of color, areas that are highly segregated in terms of race or income, are going to be the places where we would see, in all likelihood, clusters of illness,” Scott Frank, the Case Western professor, said. In neighborhoods like these, people may have larger households and smaller living spaces, and may not be able to afford to stay home, putting themselves at risk each day while continuing to work.
Frank’s grim prediction, made when I spoke with him in mid-March, is already coming true. According to recent data from health officials in New York City, several neighborhoods with the lowest median household incomes were among those with the highest number of confirmed cases of COVID-19. This is terrible for the residents of those neighborhoods, but it may also be bad for everyone: One study in Delhi, India, found that outbreaks of influenza in the poorest parts of the city propelled the spread of the disease more widely.
Moreover, the long-standing, intractable problems in many lower-income areas, whether urban or rural, won’t be put on hold during a pandemic. “A lot of communities are already dealing with things like being over-policed, police violence, excess pollution exposure, and unemployment,” Hedwig Lee, the sociologist, said. “There are other [things] that have been impacting communities in a large-scale, wholesale way—some currently and some for many generations—and that makes this even scarier in terms of what it will look like once we get through this storm.”
Among these large-scale problems is the unevenness of internet access in some areas. As of 2017, something like 30 percent of American households didn’t have a broadband internet connection, and millions of people only connect to the internet through their phones, frequently with meager data plans. “With this particular pandemic, the guidelines are changing so quickly that immediate access to good information is absolutely required and absolutely at risk with access issues and not being online permanently,” Mark Cameron, a medical professor at Case Western, said.
The fates of different places are not predetermined, though—city- or statewide public-health orders matter a lot. One telling example comes from autumn 1918, when American cities responded to the flu pandemic with many of the same social-distancing measures that are now in place across the U.S. Infamously, Philadelphia hosted a patriotic wartime parade with some 200,000 attendees (more than a tenth of the city’s population) a week and a half after confirming its first case of influenza, and didn’t close down schools or forbid public gatherings until another five days after the event. St. Louis, meanwhile, canceled most public gatherings and had flu patients isolate themselves just two days after detecting its first case. During the four-month stretch of the pandemic at the end of the year, Philadelphians were, by one study’s accounting, roughly twice as likely as St. Louisans to die from it. A separate 2007 study looking at 43 cities’ pandemic-fighting strategies 100 years ago found that “early, sustained, and layered application” of measures such as social distancing and public-event bans was associated with reducing the impact of the outbreak.
As Ronald Brownstein has written in The Atlantic, many state governments’ responses to the present crisis have differed along political lines, with liberal leaders generally taking swifter action than conservative ones. At least partly as a result of local leaders’ directives, there was a pronounced difference in how many Americans in different states stayed home in the month of March. And that may go on to play a role in the toll the pandemic takes in different areas.
The many divides in American society that will shape people’s experience of the pandemic don’t exist in isolation. Instead, they compound and overlap, increasing the risk that certain people will endure the more devastating of the two pandemics.
Some of that interplay may be a matter of bad luck. Perhaps you’re more vulnerable to COVID-19 because you have asthma, and your partner happens to work at a hospital and might bring the virus back home. But some of these patterns are not a product of chance. People with less money are likelier to have chronic health conditions, and also to live near one another, making residents of many lower-income neighborhoods doubly vulnerable. In this way, American inequality produces clusters of disadvantage, not unlike a disease.
The coronavirus will be indiscriminate, harming some Americans unpredictably, regardless of race or class or any other category. But at the same time, much of the harm it brings—far too much—will be predictable.