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Interpersonal and Structural Violence in the Wake of COVID-19

Article in American Journal of Public Health · November 2020

DOI: 10.2105/AJPH.2020.305930

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 AJPH COVID-19

busted and job insecurity and

Interpersonal and Structural Violence social inequality increased. The
global narcotics industry filled the
in the Wake of COVID-19 economic vacuum left by shut-
tered factories. Addiction mar-
kets became a desperate source of
informal employment and gen-
erator of occupational injuries for
Hospitals are struggling with outcomes at the population level. were unable to cover a $400
poor urban youths. Expelled
recurrent surges of COVID-19 Examples of structural vulnerability emergency expense. Historically
from the legal economy, they
patients from low-income com- include housing insecurity, poverty, racialized wealth inequality com-
were shunted into entry-level
munities of color across the United incarceration, racism in health care pounds the racist and classist con-
workforces at the violent retail
States. Emergency departments and criminal justice settings, and sequences of these economic
face increasing rates of firearm vi- shocks. From 2001 to 2016, the end points of the global narcotics
location within precarious legal labor
olence patients despite overall markets (the box on page 1660 wealth of upper-income–tier chain.
decreases in emergency service provides more detail).2 families increased 33%, and that of The 1980s policy response of a
volumes. In Los Angeles County, COVID-19 mortality rates are middle- and low-income families zero tolerance “war on drugs,”
California, where we practice, double in poor communities, which decreased 20% and 45%, respec- increasingly harsh and racist
intersecting COVID-19 and vio- are often segregated by both race tively. This catapulted the upper sentencing enhancements, mas-
lence pandemics are devastating and class in the United States. In Los income group to 7.4 and 75 times sive investments in a carceral
low-income inner-city neighbor- the wealth of the other groups, infrastructure, cutbacks to com-
Angeles County, low-income zip
hoods historically subject to racism, respectively. Meanwhile, corpo- munity and social programs, and
codes have triple the COVID-19
public–private disinvestment, po- rations protect their bottom lines, lack of gun control created a
mortality rates of wealthy ones.
lice brutality, and mass incarcera- and public health departments predictable recipe for disaster.
Nationwide, death rates are six times
tion. This deadly pattern appears to forecast austerity budgets that are Domestic, interpersonal, crimi-
higher in predominantly Black
be occurring in emergency rooms already causing services to be nal, and suicidal violence rose in
versus White counties. Before the
slashed.4 the community. Battered and
in poor, segregated neighborhoods COVID-19 pandemic, firearm vi-
across the country. bullet-ridden youths flooded
olence deaths were already 14 times
urban hospital trauma units.5
higher for Black than for White
Health care systems responded
men. Understanding the intersec-
by spawning a new high-tech,
tion of racism, poverty, and violence
VIOLENT LESSONS costly discipline of emergency
THE TOXICITY OF is core to understanding and
FROM US HISTORY trauma care at the expense of
SOCIAL INEQUALITY remediating the cascade of toxic
In Los Angeles County, as in neighborhood public hospitals,
The social and economic dam- socioeconomic breakdown
most rust-belt cities from the preventative care, and public
age unleashed by COVID-19, like unleashed by COVID-19.3
end of the Korean War (1953) health. The American College of
cholera and hurricanes, is not ran- By mid-September 2020, more
through the early 1990s, homi- Surgeons published guidelines
dom. Global warming and indus- than 60 million people had applied
cides rose against the backdrop of for optimal care of injured pa-
trial agriculture have shaped the for unemployment in the United
deindustrialization. Unions were tients in 1976. Emergency
burden of COVID-19 mortalities; States since the beginning of the
thus, COVID-19’s mortal impact is pandemic. A global economic re-
defined as much by socioeconomic cession is teetering into a Great ABOUT THE AUTHORS
Shamsher Samra and Dennis Hsieh are with the Department of Emergency Medicine,
inequities as it is by viral biology.1 Depression worse than that of the Harbor-UCLA Medical Center, Torrance, CA. Todd Schneberk is with the Department of
Disasters and contagions early 20th century. Skyrocketing Emergency Medicine, Los Angeles County–USC Medical Center, Los Angeles, CA.
exacerbate social forces driving unemployment rates propel pre- Philippe Bourgois is with the Center for Social Medicine and Humanities, Department of
Psychiatry, University of California, Los Angeles.
neighborhood-level structural vul- cariously poor people to scramble Correspondence should be sent to Shamsher Samra, Assistant Professor of Emergency
nerabilities—often referred to by for income by any means neces- Medicine, Department of Emergency Medicine, Harbor-UCLA, 1000 W Carson St, Building
epidemiologists as individual-level sary. Even before the pandemic, D-9, Torrance, CA 90502 (e-mail: [email protected]). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints” link.
“social determinants.” These almost 40% of the US population This editorial was accepted August 13, 2020.
associate with poor health lived paycheck to paycheck and https://doi.org/10.2105/AJPH.2020.305930

November 2020, Vol 110, No. 11 AJPH Samra et al. Editorial 1659
AJPH COVID-19

COVID-19 global pandemic

SOCIAL FORCES DRIVING NEIGHBORHOOD-LEVEL STRUCTURAL offers health care providers
VULNERABILITY TO VIOLENCE SINCE THE KOREAN WAR unique opportunities for public
advocacy, policy reform, and
Deindustrialization Job loss, chronic unemployment, decimation of unions, community-centered interven-
plummeting legal labor force participation rates (especially tions that must be recognized as
among youths) essential for effective personal-
Rising levels of social inequality and wealth disparities Poverty, social precarity, ethnic/racial/class segregation ized quality medical care.
Public–private sector services disinvestment Real estate redlining, reduction in public subsidies to the poor The US model of concen-
and for education, expansion of urban/rural wastelands trating high-tech, expensive
(abandoned property, toxic dumping, deserts of health care/ hospital trauma care for violently
food/public amenities) injured patients in centralized
Rise in underground economies Narcotics markets, sex strolls, gang-based territorial control, locations far from low-income
white collar crime and other corporate/financial capital communities has obviously failed
racketeering schemes to engage with the structural
forces that fuel unacceptable rates
Historically unprecedented public investment in carceral War on Drugs: routinization of police brutality/corruption/
of injury and reinjury, unad-
infrastructure racism, racial/class disparities in punitive sentencing
dressed post-traumatic stress
Gentrification Race-/class-based population displacement, predatory disorder, and other toxic so-
corporate profiteering cial sequelae. Alternatively,
hospital-based violence inter-
vention programs offer a practical
medicine became a board- social support systems frayed by rituals) that contain youth vio- community-centered vision of
certified medical subspecialty in scarce economic resources. lence in all societies were weak- sociostructurally essential trauma
1979. Survival exigencies throw ened. Social supports require care in moments of crisis. These
The United States drew on unemployed youths into in- publicly funded resources to be programs decrease reinjury
military logistics and technolo- formal economies, increasing sustainable among vulnerable rates, justice involvement, and
gies developed in its Korean and their exposure to violent populations in large, deperson- health care costs by offering
Vietnamese invasions and covert crime and neighborhood alized urban centers. Cycles of longitudinal accompaniment and
insecurity. economic precarity, shifting wraparound services to violently
campaigns. Modern trauma sys-
Opportunistic politicians, narcotics epidemics, and the injured patients and their
tems excel at street corner triage
populist media, and careerist generalized scramble for scarce families. They reduce rehospi-
with rapid patient transport to
policymakers instrumentalized resources foments individualistic talization by augmenting
designated trauma centers and quality of life. This strengthens
the rise in public insecurity dur- victim blaming, racism, xeno-
protocolized resource-intensive solidarity links in stressed
ing the 1980s. They advocated phobia, and generalized distrust
treatments. Posttrauma survival and cynicism. Given the dispro- communities.
and implemented racist profiling
improved, but neighborhood- portionately destructive impact The incorporation of peer-
and militarized policing. A mas-
based social determinants of of COVID-19, it is predictable based accompaniment is espe-
sive prison infrastructure was
health were left unaddressed.6 that these structural vulnerabil- cially crucial for moving beyond
built to contain the rising eco-
Social inequality, racism, and ities will worsen as they are met reactive crisis responses. Hospital-
nomic dislocation, suffering, and
militarism are patently bad for by ongoing police violence, si- based violence intervention pro-
public health. When vulnerable protest generated by deindustri- grams create preventative health
lence, and withdrawal of existing
individuals are denied access to alization and community disin- links with injured patients, families,
programs.
meaningful employment and vestment. Predictably, the neighbors, and social service pro-
deprived of socioeconomic sup- systemic routinization of in- viders and educational and voca-
ports, as is occurring during the creasingly harsh, racist policing tional resources. Most importantly,
COVID-19 pandemic, the result tactics, enhanced sentencing in it can expand the purview of health
is disastrous. When state inter- courts, mass incarceration, and WHAT IS TO BE DONE? systems and providers to include
ventions generate suffering and service cutbacks devastated the Austerity social service budget advocacy and policy reforms that
personal stress, they manifest as primarily urban communities of cuts contradict a rising nation- could mitigate upstream social
individual-level violence to self, color they targeted in former wide recognition that “Black forces and structural determinants
kin, friends, and acquaintances. industrial factory zones. More Lives Matter” and call for shifting of health, including vulnerabilities
These rising levels of ostensibly subtly, social support systems tax dollars into agencies with to violence.7
interpersonal (but structurally (family, face-to-face community supportive rather than repressive COVID-19 and violence is a
driven) violence undermine solidarities, collective cultural priorities. The unprecedented disastrous syndemic of structural

1660 Editorial Samra et al. AJPH November 2020, Vol 110, No. 11
 AJPH COVID-19

violence changing our world and 2017;92(3):299–307. https://doi.org/10.

1097/ACM.0000000000001294
survival chances. In solidarity with
3. Yancy CW. COVID-19 and African
vulnerable patients, we need to Americans. JAMA. 2020;323(19):1891.
engage with communities to de- https://doi.org/10.1001/jama.2020.
liver sustained upstream structural 6548
interventions that will outlast 4. Horowitz JM, Igielnik R, Kochha R.
Most Americans Say There Is Too Much
humanitarian crisis moments. Economic Inequality in the US, but Fewer
Economic injustice and racism Than Half Call It a Top Priority. Wash-
disproportionately kill or incapac- ington, DC: Pew Research Center; 2020.

itate our most structurally vulner- 5. Friedman J, Karandinos G, Hart LK,

Castrillo FM, Graetz N, Bourgois P.
able patients, whether from Structural vulnerability to narcotics-
COVID-19–generated respiratory driven firearm violence: an ethnographic
and epidemiological study of Phila-
failure or from a spray of bullets. By delphia’s Puerto Rican inner-city. PLoS
diagnosing the immediate pathol- One. 2019;14(11):e0225376. https://doi.
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with underlying structural violence 6. Ramos NJF. Worthy of Care? Medical
Inclusion From the Watts Riots to the Building
in society, health care providers of King-Drew, Prisons, and Skid Row,
and researchers can help the 1965–1986 [PhD dissertation]. Los
United States avoid reliving failed Angeles, CA: University of Southern
California; 2017.
history and stem the intertwined
7. Juillard C, Smith R, Anaya N, Garcia A,
pandemics of COVID-19 and vi- Kahn JG, Dicker RA. Saving lives and
olence devastating urban com- saving money: hospital-based violence
intervention is cost-effective. J Trauma
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258. https://doi.org/10.1097/TA.
Shamsher Samra, MD, MPhil 0000000000000527
Todd Schneberk, MD, MS
Dennis Hsieh, MD, JD
Philippe Bourgois, PhD

CONTRIBUTORS
S. Samra and T. Schneberk wrote the first
draft of the editorial. P. Bourgois con-
tributed critical revisions. All authors
conceptualized the editorial and contrib-
uted to the final version.

ACKNOWLEDGMENTS
The research discussed in this editorial was
supported by the National Institutes of
Health (NIH; grants UL1TR001881,
DA04964).
We would like to thank Vincent Chong,
Rochelle Dicker, Sumala Haque, Tony
Kou, Joseph Friedman, Javier Martinez,
Gilbert Salinas, and Adrian Yen for their
contributions to this editorial.
Note. The content of this editorial
does not necessarily represent the views
of NIH.

CONFLICTS OF INTEREST
The authors have no conflicts of interest to
declare.
REFERENCES
1. Davis M. C’est la lutte finale?
COVID19 and the crisis of humanity. Irish
Marxist Review. 2020;9(27):12–25.
2. Bourgois P, Holmes SM, Sue K,
Quesada J. Structural vulnerability:
operationalizing the concept to address
health disparities in clinical care. Acad Med.

November 2020, Vol 110, No. 11 AJPH Samra et al. Editorial 1661

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