The Pandemic Divide: How COVID Increased Inequality in America

Book Title: The Pandemic Divide: How COVID Increased Inequality in America

Editors : Gwendolyn L. Wright, Lucas Hubbard, and William A. Darity Jr

Publication Details: Durham: Duke University Press, 2022, 312pp., paperback, $27.95

For years, family physicians have advocated a biopsychosocial model of medicine. Slowly, health systems, payers, and government policy makers awakened and began to consider the social determinants of health (SDoH). Then came COVID-19. Immediately everything narrowed in focus to merely the biological: stop the virus. As society shut down, there was no consideration of economic stability, education, health care access and quality, neighborhood environments, or social context. ¹ It may be years before we know whether this response to the pandemic had a net positive, neutral, or negative effect on overall morbidity and mortality. The Pandemic Divide suggests that the result was largely negative for at least some segments of society. This collection of essays, with the primary intent of illustrating “… the broad reach of structural racism” (p. xii), explores how COVID-19 and the resulting policies disproportionately worsened health. The authors point out that while most studies of the pandemic’s effects on Black and Latino communities focus on pre-existing health disparities, effects on other aspects of their lives (read: SDoH) are neglected (p. 69). A major contribution of this book is its examination of these “other aspects.” Citing the limited data that exist, the authors incorporate personal stories that illustrate the devastating impacts.

Pandemic policies wrought economic instability. The burden of these policies fell heavily upon disadvantaged Black and Latino communities, where jobs permitted limited to no ability to work remotely. They faced increased infectious exposure, being classified disproportionately as “essential” workers. Black-owned businesses were more vulnerable, often having limited reserves, liquidity, and credit access compared to other businesses. Efforts to blunt the economic effect of quarantine policies (eg, Paycheck Protection Program, subsequent stimuli) were not distributed to the need, widening the income and wealth gaps.

Another victim of official policy was educational access and quality. Compared with in-person instruction, virtual learning fails. There was significant learning loss across the board, and the achievement gap for students of color increased. For example, speech therapy for Latino English learners “rel(ies) heavily on bilingual peers for information about the social practices of language use and for translation and clarification of learning tasks” (p. 250). Clarification of learning tasks and social practices of knowledge acquisition and use applies across academic subjects for all students. There was a stark contrast between the successes of white-collar parents (often with a bachelor’s degree or higher) supervising school at home while working remotely and blue-collar parents still working at their job site, with their children less closely supervised. Challenges among the less affluent in obtaining hardware, accessing the internet, and navigating the online platforms were often insurmountable, creating a digital divide. Inefficacy of online learning was apparent in higher education: online learners were more likely to withdrew from classes, have lower grades, and drop out completely. Increased disparity in the employment of adjunct vs tenured faculty (the former having a higher proportion of underrepresented populations) emerged.

Health care access and quality suffered, with Black and Latino populations disproportionately affected. Vaccination sites were inaccessible and both chronic and acute care were less available due to clinic closures or limited hours, especially in disadvantaged neighborhoods. Access was further compromised by loss of insurance (due to loss of jobs alluded to earlier). This increased vulnerability of populations already at greater risk for severe COVID-19 due to pre-existing conditions.

School closures and the digital divide, job loss, health care access, and disproportionate failure of Black-owned business affected another SDoH, namely neighborhood and the built environment. Closure of other neighborhood businesses further rendered services and infrastructure inadequate.

Pandemic policies altered social and community context. Perhaps one of the more significant social injuries to Black communities was pandemic policies on religious practice. “Religion has mitigated the full impact of certain negative outcomes for blacks in the past” (p. 70), but with enforced closure of houses of worship there was a loss of this significant source of social support.

Disasters follow a cycle of preparation, response, recovery, and mitigation. COVID-19 and the response to it was a disaster. The authors propose high-return interventions to aid in the recovery, mitigate the damage to Black and Latino populations, and better prepare for the next event. These focus on child education and health, adult job training, criminal justice, housing, wealth building, and intergenerational interventions. This is the right thing to do. Our vulnerable populations, whether by error or design, present an early warning sign: policies and practices that hurt them ultimately harm even those who have advantage in the SDoH. If pure compassion and justice doesn’t move society to avoid bad policies, selfish pragmatism must!