VoxEU Column COVID-19

The COVID-19 upheaval scenario: Inequality and pandemic make an explosive mix

Estimates by medical experts suggest that the US does not have the hospital capacity to handle a spike in COVID-19 cases as large as the one seen in Italy. Avoiding triage situations at US hospitals is particularly important given the health vulnerability of so many Americans, the incipient rage stemming from decades of economic malaise and rising inequality, and the widespread ownership of guns. The solution is to err on the side of caution by implementing immediate, large-scale social distancing.

On 11 March, Marc Lipsitch, Professor of Epidemiology and Head of the Centre for Communicable Disease Dynamics at the Harvard T H Chan School of Public Health, told us how worried he was about the future: “The situation we should be worrying about is the situation four weeks from now, not the situation now.”1 

The source of this concern was not the few thousand cases of COVID-19 reported in the US at that date. American testing has been slow due, in part, to early fumbles by the Center for Disease Control and Prevention (Fink and Baker 2020). That means, Lipsitch argues, that the true extent of the disease in the US is unknown:

"Scientists, Lipsitch noted, guess that the true number of cases is somewhere between 'tens of thousands and hundreds of thousands'."

This, alone, is a big problem. The US has few empty hospital beds. 

"We do not have capacity"

"We do not have anywhere near capacity to take care of tens of thousands of people who might need hospitalization.” Dr. Jha, Harvard Medical School.

In early March, Dr Ashish Jha, Director of the Harvard Global Health Institute, internist, and Professor of Medicine at Harvard Medical School, investigated the state of preparation of Massachusetts hospitals if there was an onslaught of COVID-19 patients:

“At any given time in Massachusetts, we think there are [3,000 to] 4,000 hospital beds open at most,” he said, “if you start doing the numbers, you very quickly realize we do not have anywhere near capacity to take care of tens of thousands of people with [COVID-19] who might need hospitalization.

"Some of the best epidemiologists in the world are estimating that between 40 and 70% of adults will end up getting an infection. Even if we begin with that low end of 40% of adults in Massachusetts, that's 2 million people getting infected … If we take data from China that says 20% of people needed hospitalizations, that's 400,000 hospitalizations. Even if we said 'No, that's too many, we can cut that in half,' that's 200,000 hospitalizations.”2

Trying to treat a six-digit number of patients with a four-digit number of beds will create problems. 

Unless the arrival of new cases can be spread out by social distancing policies that reduce the rate of infection, hard choices must be made. Economists call it rationing. In medical jargon, it’s called ‘triage’. This is happening in Italy right now.

Italian hospitals overwhelmed

Italy has a world-class, well-funded healthcare system that has been overwhelmed by an explosion in the number of patients with COVID-19 that need hospitalisation. 

Dr Pier Giorgio Villani was on duty in the hospital in Lodi, Lombardy, when the first COVID-19 patient was transferred from nearby Codogno. "We ran out of ventilators, masks … on day two,” he said, "it was a big mess" (Winfield 2020).

"It’s something that makes you change completely how you run a hospital.” Dr Roberto Rona

Dr Roberto Rona, in charge of intensive care at the Monza hospital, near Milan, said: “It’s not a wave. It’s a tsunami. It’s something that makes you change completely how you run a hospital” (Winfield 2020).

The only solution? Spread out the number of new cases arriving at the hospitals. 

Buying time will save lives

Since we have no 21st century tools to fight COVID-19, we must fall back on physical strategies that slow the infection rate. These strategies involve lockdowns, quarantines, area containment, business closures, travel bans, and social distancing policies. 

Containment policies are economically costly, but it’s time to admit “a recession is a public health necessity” (Hamilton and Veuger 2020)

By reducing the frequency with which people who are infectious meet people who are susceptible, containment policies lower the speed at which the disease spreads. 

This, in turn, slows the flow of people showing up for hospitalisation. The goal is to keep the flow of daily severe cases to within the capacity of the hospital system for new admissions. This ‘flattening the curve’ point is illustrated schematically in Figure 1. 

Figure 1 Flattening the curve saves lives and reduces the chance of civil unrest

Avoiding triage situations at US hospitals is particular important given the health vulnerability of so many Americans, the incipient rage that has resulted from decades of economic malaise, and the widespread ownership of guns. Would it be an exaggeration to call this a powder keg situation? 

American inequality in wealth and health

For two decades, millions of Americans have already been facing financial and health difficulties.  A recent survey showed that 40% of Americans could not come up with $400 to cover an emergency without borrowing or selling something (Federal Reserve 2019). One out of four had to deny themselves some form of healthcare because they couldn’t afford it. 

Forty million Americans live in poverty. A quarter of US children live in poverty. The country has the highest rate of obesity in the developed world, and it ranks below Lebanon for access to water and sanitation. US men, in particular, have just been giving up in record numbers – especially those who never went to university. The share of males aged 25 to 55 in work, or looking for work, has fallen steadily since the 1970s, especially those with a high-school education or less. 

US economic mobility dropped steadily since the 1970s. If you were born in the US in 1970 in an average household, you would have a four-in-five chance of earning more than your parents. Ten years later, the odds had dropped to 50-50. Americans with low education who started working after the 1970s have faced a much harder life, with a much dimmer future, than their predecessors. With each decade, statistics show their prospects are getting worse. 

And then there are the 'deaths of despair'.

Deaths of despair

Work by Anne Case  and Angus Deaton has shown the mortality rate among US whites aged 45 to 54 with only high school degrees – both men and women – rising dramatically since the late 1990s. “Half a million people are dead who should not be dead,” Deaton told the Washington Post (Bernstein and Aschenbach 2015). These people endured “deaths of despair”, in their words, and each decade we record more deaths of despair in all parts of the US. 

We can tease apart the proximate causes of death – some are from drugs, some by alcohol addiction, and others by suicide – but Case and Deaton argue that, in the end, they are the same death: “In a sense, they are all suicide – either carried out quickly (for example, with a gun) or slowly, with drugs and alcohol.” 

This group of people are less likely to have a job or the support of a marriage. They have worse physical and mental health. All these factors, Case and Deaton argue, have caused the higher death rates by kicking out the social and economic supports that help most of us get through hard times. 

Many of these people will catch COVID-19; about 20% of those will need hospital treatment. Will they get it? In Italy, where medicine is run by the state, medical priorities are set by doctors who care about patients; personal wealth is not really a consideration. Can we say the same about the US?

The unknowable inevitable future

In my 2019 book, The Globotics Upheaval: Globalisation, Robotics and the Future of Work, I conjectured that the underlying discontent would provoke backlash, especially in the US, with the trigger being a loss of good jobs. Speculating further, I suggested that Big Tech might be the focus of the anger.

COVID-19 has forced me to reconsider. Witness the shock that COVID-19 is causing in societies that are significantly less stressed than the US. I am thinking that a potential trigger in the US may be loss of life, not loss of jobs. The focus of the anger may pivot to Big Medicine. 

Imagine the potential public reaction to a news report in the near future. This imaginary local TV segment shows an elite getting priority access to intensive care in private hospitals while middle-income citizens are being turned away from public hospitals. The hospital spokesperson, in this imagined future, explains with a shrug of regret that there are just not enough beds for everyone. 

Does this imagined scenario strike you as realistic? If the answer is yes, then you may have an easy time imagining that the story ends violently – much worse than people fighting over toilet paper. 

It’s been a long time since the US saw violent upheaval on the streets, but maybe not as long as you think. In 1991, four white Los Angeles police officers were videoed beating a black motorist, Rodney King. A year later, three were acquitted of assault, with the jury failing to agree on charges against the fourth. Six days of rioting in Los Angeles followed. More than 9,000 National Guard troops and the US Marine Corps were called to restore order. By the time the streets were quiet, there had been 63 deaths and 2,383 injuries. More than 1,000 buildings were partly or completely destroyed. Almost 12,000 people were arrested. 

The Rodney King riots resulted from a unique combination of hostility to the police, rising anger at unequal treatment by the justice system, and the trigger of the surprise acquittal. But that’s always the case with upheavals. They are always a unique combination of hostility, anger, and a trigger. 

The spread of the COVID-19 pandemic in the US, and the consequences for Americans’ healthcare, are unknowable. But we should be watchful. Some of the biggest upheavals in history – the uprisings of 1848, the Russian Revolution of 1917, and the rise of fascism – were built on a foundation of long-lasting economic malaise and a burning sense of inequality and injustice. 

Thinking ahead and flattening the curve

If we open our eyes to Lipsitch’s and Jha’s arithmetic, it seems clear that the US needs to urgently undertake policies to slow the flow of COVID hospitalisations. On 11 March, Lipsitch called the lack of testing for the virus so far a "debacle", but focused on what this means for the immediate future. “We need to err on the side of caution at this point,” he said, calling for immediate, large-scale social distancing.

The aim of social distancing is to keep the peak number of cases at a level the healthcare system can handle. It is critical that social distancing policies apply everywhere, he argued, because that lack of testing means that officials have little idea where the disease may be most severe. Lipsitch cited the case of a meeting of 175 people at the biotech firm Biogen. That one meeting has resulted in 70 COVID-19 cases so far.

“There’s a real danger of accelerating the epidemic if you have a large number of people together,” Lipsitch said. “The goal is to minimise the number of contacts between people.”

The future is unknowable, but we have to think about it; one version or another of the future is coming whether we like it or not. Scenarios need to be thought out and prepared for. I would suggest this ‘COVID upheaval scenario’ is one that we should be thinking about. 


Baldwin, R (2019), The Globotics Upheaval: Globalisation, Robotics and the Future of Work, Oxford University Press.

Bernstein, L and J Aschenbach (2015), "A group of middle-aged whites is dying in the US at a startling rate", Washington Post, 2 November.

Eichengreen, B (2018). The populist temptation. Economic grievance and political reaction in the modern era, Oxford University Press. 

Federal Reserve (2017), “Report on the Economic Well-Being of U.S. Households in 2016”, May.

Federal Reserve (2019), "Report on the Economic Well-Being of U.S. Households in 2018 - May 2019", May.

Fink, S and M Baker (2020), “‘It’s Just Everywhere Already’: How Delays in Testing Set Back the US Coronavirus Response”, New York Times, 10 March.

Hamilton, S and S Veuger (2020), “A recession is a public health necessity. Here’s how to make it short and sharp,” The Bulwark, 14 March.

Jolicoeur L, and L Mullin (2020), “Harvard Global Health Expert: Mass. Hospitals Face Capacity Problem If Coronavirus Cases Spike Quickly,” WBUR, 10 March

Powell, A (2020), "‘Worry about 4 weeks from now,’ epidemiologist warns", The Harvard Gazette, 11 March.

United Nations (2017), “Report of the Special Rapporteur on extreme poverty and human rights on his mission to the United States of America”. 

Winfield, N (2020), "‘Not a wave, a tsunami.’ Italy hospitals at virus limit," Associated Press, 13 March.


1 Cited in Powell (2020).

2 Cited in Jolicoeur and Mullin (2020).

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