COVID-19 infiltrated every socio-economic divide in Virginia. The next pandemic doesn’t have to.

Jennifer Simmons receives the Moderna COVID-19 vaccine during "Senior Weekend" at Richmond Raceway in Richmond, Va., February 2, 2021. (Parker Michels-Boyce/ For the Virginia Mercury)

Just a few months into the COVID-19 pandemic, data began to suggest that disparities, especially disproportionate death rates , were forming on top of all too familiar divisions of race, economics and geography. This prompted Al Sharpton to opine , “I am not saying the pandemic is a conspiracy to kill or target Blacks, but it is illuminating the existing racial disparities in this country that reverberate in everything from health care to jobs, housing and more.” Even in 2024, African American COVID-19 infection rates are approximately 29% higher than the rates of non-Hispanic whites in Virginia.

There is a joke in development economics: it helps to pick your parents. It’s a tongue-in-cheek reference to outcome disparities based on both where a person is born and what their parents do for a living. My mom’s family is from Western Pennsylvania between Pittsburgh and the Ohio border – an area that reminds me a lot of Southwest and Southside Virginia.

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I saw how macroeconomic decline during the 1980s and 1990s limited my family’s options. After my uncle lost his job in a steel mill, he had to drive six hours each day for work because the only decent job he could find was in Harrisburg, Pennsylvania. Ultimately, he ended up sleeping at a friend’s place in Harrisburg four days a week for over 20 years, only seeing the family on weekends until he retired. My cousin, who is almost the same age as me (I’m 43), works irregularly in food service and the gig economy to make ends meet. College wasn’t for him but the new economy that took root in Pittsburgh required advanced degrees even for entry-level roles. Now his future is even more uncertain as the economy of rural America struggles to regain its footing after COVID-19.

Following my parent’s divorce, I grew up in two neighborhoods: Arlington,/East Falls Church (EFC) in Northern Virginia and Hill East in Washington, D.C. Both were very much working-class neighborhoods back then; neither are now. Hill East was around 90% blue-collar African American. Today, the neighborhood is upwards of 80% non-Hispanic White with at least 50% of the population having graduate degrees. This change is reflected in rents, housing prices and property tax burdens that most of the people I grew up with can no longer afford.

Similarly, EFC was once full of teachers, police officers, administrators — even my elementary school’s custodian lived there. Now, only people like lawyers, finance professionals, and c-suite executives make enough to buy there. A vast majority of the residents of Hill East and EFC were able to wait out the most serious impacts of COVID-19 in relative comfort; the rest of Virginia wasn’t as lucky.

As a public policy researcher, I constantly think about structure — the things that affect a person’s outcomes but are largely pre-existing and/or beyond their ability to control. Structure-based outcomes are something I’ve seen consistently throughout both my personal and professional lives. Studying the COVID-19 pandemic was no different.

During the height of the COVID-19 pandemic , at least 49% of Arlington residents worked from home. Meanwhile in Augusta County near the West Virginia border, only 8% of workers were able to do the same. The most common industries in Arlington are classified as professional, scientific, and management while the most common industries in Augusta are educational services, health care and manufacturing. Through 2021, Augusta’s age-adjusted COVID-19 death rate was 2.25 times higher than Arlington’s, despite Arlington’s population density being 115 times greater. As a community-based researcher at VCU, I’ve seen a similar dynamic play out inside the City of Richmond between different groups that share the same spaces.

The common themes here are:

1.) Marginalized groups have often been left behind because they are forced to accept more vulnerable, less-decent employment and housing options.

2.) They generally don’t have the resources to break this cyclical poverty.

3.) Government programs designed to address these issues suffer from major gaps.

4.) These inequities inevitably lead to other serious outcome disparities, like what we saw during the COVID-19 pandemic.

My recent research , co-authored with Dr. Brittany “Brie” Haupt, illuminates how these differences in structure guided COVID-19’s disproportionate impacts in rural and minority communities in Virginia.

At the county and independent city level, we started with a simple correlational analysis that showed Virginia municipalities with greater percentages of African Americans and those outside of metropolitan statistical areas suffered greater levels of COVID-19 infections, hospitalizations and death rates (both crude and age-adjusted). We then took socio-economic data collected before the COVID-19 pandemic to analyze how structure interacted with race and rurality to produce these disparate COVID-19 outcomes. Using a procedure called structural equation modeling , we partialed out direct and indirect effects, as well as analyzed likely causality direction by modifying the covariance functions and comparing their likelihoods.

In our model, we were able to isolate a set of workforce roles as the primary cause of disproportionate infections in more rural and minority communities. Once we included a variable for this, the direct covariance between race, rurality and COVID-19 infection rates lost statistical significance in the case of rurality, and, in the case of race, became a statistically significant negative. Additional analyses showed there was still a statistically significant positive indirect path. Similarly, once we added data to our model on underlying community health (diabetes, premature death rates, etc.), the direct paths between race, rurality and COVID-19 hospitalizations and age-adjusted death rates lost statistical significance. Also similarly, statistically significant positive indirect paths remained. Thus, we believe we likely isolated the biggest drivers of COVID-19’s disproportionate impacts in marginalized communities.

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Our conclusions are fairly straightforward — before vaccine uptake was widely utilized, patients with COVID-19 either made it through or perished based on their underlying health status and other characteristics. These traits are not randomly distributed throughout Virginia’s population, rather they are concentrated based on the structures many people are either born into, migrate to, or are displaced to. We believe future pandemics will play out in similar fashion given the nature of epidemiology.

Furthermore, chronic conditions like diabetes and hypertension — which were the biggest driver of COVID-19 deaths in our model — are managed and reduced instead of cured. This requires sustained resources for years if not decades. Unfortunately for many people and localities that need them, these resources are either not currently available, affordable or feasible, given the dynamics of structure. The at-risk jobs we identified in our model are less likely to offer health insurance or pay high wages but they are unstable and often lack promotion potential.

Local governments in these areas are often not able to offset this because of the same economic structures that affect employment opportunities. Local governments rely overwhelmingly on business and property taxes. But if an area is economically distressed and/or has a greater marginalized population, this means that the government  has less money but also a greater need. Thus, even with the CARES Act, we saw how metropolitan areas like the city of Richmond were able to provide more resources to local businesses during COVID-19 than rural areas like Lee County. Similarly, we cannot expect marginalized or declining areas to stockpile resources on their own before the next pandemic.

In an era when Virginia consistently sees record revenue surpluses in the billions , there is no good reason why health disparities, especially like what we observed during the COVID-19 pandemic, should be so stark or consistent. In 2022, the U.S. Census Bureau listed Virginia as the 13 th wealthiest state by median income , and the same year, Virginia’s health system was ranked 20 th out of 50 states by the Commonwealth Fund . There are 86 Virginia jurisdictions  currently designated as medically under-served areas (MUAs). Even in wealthy counties like Arlington, there are multiple census tracts that are also classified as MUAs .

While Virginia increased healthcare funding since the COVID-19 pandemic, per the Virginia Public Health Association (VPHA) , most of it (approximately 85%) was a result of Federal CARES Act funding rather than sustained appropriations from the general fund. Understandably, the major focus of the increased spending is on communicable disease spread, but there is little mention of managing chronic conditions that our research suggests are the biggest factors in patient survival. Also, while Virginia requires COVID-19 workplace-based protections that follow CDC standards , the current disparities in infection rates suggests much more can be done. And, employers shouldn’t be asked to bear these costs and responsibilities alone. So, where do we go next?

Virginia must invest in more federally-qualified community health centers, social workers who specialize in assisting marginalized populations, and accessible wellness programs targeted towards chronic disease management. These improvements will keep more people healthy, reduce structural inequality and save lives during the next pandemic. Surely if Virginia has money for casino developments , sports stadiums and Fortune 500 company relocations , it has money for these structural healthcare investments well. We owe nothing less to the more than 22,000 Virginians who didn’t survive the COVID-19 pandemic.

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