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More than 110 000 people have died in the US because of severe acute respiratory syndrome coronavirus 2, a pathogen that was unknown just 6 months ago. Ubiquitous fear and anxiety that accompanied the emergence of the new coronavirus led to widespread limits on physical contact in attempts to mitigate the spread of the virus. That in turn brought the US economy to a halt, resulting in more than 40 million people filing for unemployment, approximating numbers not seen since the Great Depression of the 1930s. In the past month, the killing of several unarmed black men and women—Ahmaud Arbery, Breonna Taylor, and George Floyd— has spurred widespread civil unrest, with night after night of demonstrations demanding reform of systems of policing that have disproportionately harmed black people for centuries.
These 3 events, the pandemic, massive unemployment, and the recent protests, have occurred concurrently. Federal and state officials offer daily summaries of coronavirus disease 2019 (COVID-19) cases and deaths. At the same time, millions of people across the country have been adversely affected by unanticipated unemployment, with higher unemployment rates among black and Hispanic workers compared with white workers. The resurgence of anger at long-standing racism and racial inequities was added to the anxiety and tension of the pandemic, creating a combustible scene of national civil unrest. Deep political divisions have shaped the moment from the start. Partisan divides have informed opinions around the extent of a national shutdown needed to mitigate pandemic spread, a pandemic that has disproportionately led to the deaths of black people, and about how to address the legitimate concerns of thousands of individuals protesting the murder of black men and women.
Each of these 3 national events would be sufficient to dominate any given year’s news cycle, yet all 3 have unfolded in the first 5 months of the year 2020. There is much to be written about this moment with the calm dispatch of time, and it remains to be seen what narratives will endure in the public mind decades hence. But the narrative that should emerge centrally—which influences each of the 3 events the country is experiencing—is the role of underlying divides in making the US vulnerable to, and shaping the contours of, each of the events of 2020.
People in the US live in a manifestly unequal country, with multiple divisions cleaving the country into haves and have nots. Deep divides in socioeconomic position readily belie the US as a classless society. Although public narratives around income inequality have long entered the political conversation, many of these narratives focus on the richest 1%, suggesting that the wealthiest few accumulate disproportionate resources while the rest of the country—99% of the population—opposes this in solidarity. But this narrative has obscured the underlying architecture of division in the country. For example, over the past 40 years, incomes have been increasing consistently for one-fifth of the country, the richest 20%, while they have increased only marginally for the other 80%. The same richest 20% are much more likely to be married, have savings, and have college degrees than the poorest 80%.1 Importantly, the children of the richest 20% are much more likely to be in the richest 20% than in any other quintile while, conversely, it is becoming more difficult to rise economically from the lower income quintiles or receive a college education. National socioeconomic divides are not between a relative few and everyone else, but rather they are between those who are college educated and those who are not and between those who are white-collar professionals and those who are not. Moreover, the divisions are deepening over generations and entrenching class divides.
Race and ethnicity represent another core cleavage plane. The US has struggled for centuries to escape the shadow of racism and the attendant disenfranchisement of black individuals, who have foreshortened opportunity, both economic and social. A system of mass incarceration makes it 6 times more likely for a black man to be incarcerated than a white man; although black individuals make up 12% of the population, they account for 33% of individuals in federal prisons, while white individuals make up 64% of the population and account for 30% of individuals in federal prison.2 Black individuals experience racism in hiring, finding housing, and day-to-day encounters that lead to a systemic marginalization of an entire racial group. Other groups with minority identities, including Native American individuals, Latinx populations, LGBTQ (lesbian, gay, bisexual, transgender, queer) persons, and immigrants, often encounter similar forces of marginalization, creating in and out groups that compound and deepen these divides.
It is well established that these socioeconomic and racial/ethnic divides also have contributed to deep and longstanding health divides. Women in the richest quintile have had an increase of about 6 years in life expectancy over the past 40 years, whereas life expectancy for women in the other 4 quintiles has not changed substantially in the same time period.3 Black individuals have 3.5 years fewer life expectancy at birth than white individuals. A black man living in Arkansas has a life expectancy of 68 years; a white woman living in Minnesota has a life expectancy of 84 years.4 Persons of color with fewer socioeconomic resources are far more likely to have poor health than persons who are white. Poor black women are more likely to deliver a newborn with low birth weight than poor white women, suggesting a compounding of the consequences of race and low income.5
None of this is new; this is the condition of the US over the past nearly 50 years. As a consequence, US health has fallen well behind that of its peer nations. Since 1980, life expectancy in comparable countries has increased by 7.8 years; in the US, it has increased by 4.9 years. US life expectancy is now 4 years less than in other peer nations, and health outcomes in the US are increasingly worse among all age groups than peer nations, with the exception of persons older than 75 years when investment in expensive end-of-life care gives the US better health than many other high-income countries.6
But the US has, as a country, accepted this for many decades. Perhaps it is because many individuals in the US have a clear interest in maintaining the status quo. When one-fifth of the country is doing quite well, achieving material and health status comparable to other high-income countries, that proportion of the population has relatively little to gain by challenging the system that sustains these advantages. Individuals in that group have largely been running the country, serving as the politicians, business owners, and thought leaders who shape the conditions that affect everyone. As a simple example of the concentration of power in the hands of a few, all 9 current Supreme Court justices attended 1 of 2 law schools, even though there are more than 200 law schools in the US. Therefore, for a long time, those who were doing well had little reason to invest in building stable systems to protect all US residents or to invest in health as a public good. Why, after all, would those in the highest economic quintile need health to be a public good when they are able to purchase and benefit from private health care insurance?
These realities have exacerbated and been exacerbated by the events of 2020. COVID-19 emerged, triggering unprecedented anxiety that the most expensive health care system in the world may be overrun in record time, and, in turn, efforts to manage the pandemic froze the economy and lost trillions of dollars in the process. The public health system, which has been underfunded for decades, was not remotely up to the task, and the underlying poor national health made the US enormously vulnerable to COVID-19–related morbidity and mortality. But, as can be expected, the consequences of COVID-19 have not been experienced evenly. Emerging data clearly show that the risk of acquiring COVID-19 has been greater among minorities and persons of lower socioeconomic status; these same groups are also at greater risk of dying of COVID-19 once they contract the disease.7 The economic consequences has been similarly uneven. By April 2020, among the 36 million jobs lost, 40% were held by persons with an annual household income less than $40 000. Unemployment rates are estimated to be 14.2 among white individuals, 16.7 among black individuals, and 18.9 among Latinx individuals.8
It is then no wonder that the killings of unarmed black men and women have become the flashpoint for justifiable anger and civil unrest not seen since 1968. The public anger would be amply legitimate were it only about repeated acts of racial injustice with fatal consequences for people of color. It is doubly understandable as an expression of deep discontent with conditions of inequity that have affected the country for decades. Through tolerating deep socioeconomic and racial divides for so long, the US has set the stage for a catastrophic response to an unanticipated pandemic. The important emerging question is what shall the country do with the understanding that must emerge from these 3 ongoing events. The civil unrest that has galvanized the public conversation should focus the nation, once and for all, on the underlying divisions that shape the country. It would be a stain on the national conscience if this historic moment of crisis was not used to do what is necessary to rewrite a national script and create a country of real opportunity consistent with its own self-image.
Corresponding Author: Sandro Galea, MD, DrPH, School of Public Health, Boston University, 715 Albany St, Boston, MA 02118 (email@example.com).
Published Online: June 12, 2020. doi:10.1001/jama.2020.11132
Conflict of Interest Disclosures: Dr Galea reported receiving consulting fees from Sharecare and Tivity Health. No other disclosures were reported.
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Galea S, Abdalla SM. COVID-19 Pandemic, Unemployment, and Civil Unrest: Underlying Deep Racial and Socioeconomic Divides. JAMA. 2020;324(3):227–228. doi:10.1001/jama.2020.11132
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