The COVID-19 pandemic revealed many flaws in North American health care systems and sparked widespread discussion on public health reform. Here, I consider pandemic experiences under fee-for-service medicine in the United States within the global context of Western neoliberalism. When considering the media coverage of COVID-19, scholars often consider the impact of “misinformation” being circulated haphazardly and how that “misinformation” impacts the relationship, or lack thereof, between the public and health researchers (Levy, 2023; Roozenbeek et al, 2020; Wang et al., 2022). As someone who lived in the American South and worked in healthcare as an emergency room volunteer at a pediatric hospital and as a pharmacy technician at a high-volume pharmacy in the summer of 2020, I experienced that dysfunction first-hand. Using personal experience, I would also like to consider a more meta conversation that is ongoing now that the United States has declared that it is no longer in a state of pandemic (Biden, 2023). Many scholars living outside of the American South, including other countries like Canada, are having conversations about vaccination hesitancy and regionally varying infection rates (Hou et al., 2021; Okonji, 2021; Wibbens & McGahan, 2020). Due to the nature of media reporting that shows alt-right politicians and their supporters during this time, I have encountered a generalized sentiment that people in the American South are vaccine hesitant and vaccine rejectors due to a state of under-intelligence (Bolsen & Palm, 2022; Larson et al., 2022; Mamudu et al., 2023). This sentiment directly undermines the documented relationship of distrust between hesitant and avoidant populations and healthcare educators, but, from my experience, it is very common in external dialogues about the American South (Cokley et al., 2022). I argue that this regional misconception is a harmful result of media efforts to create false imagery of ideological homogeneity in the South as well as a harmful form of structural oppression that creates further health divides between already underserved communities within the South.
During the COVID-19 outbreak, after vaccinations became available to the public, the American South suffered from high rates of undervaccination that prevented the region from developing herd immunity. Studies in 2021 showed that approximately 40% of the Tennessee population was unvaccinated and that those unvaccinated populations were largely in rural communities (Alcendor, 2021; Bateman et al., 2022; Hernandez et al., 2022; Matas et al., 2023). The reason that was cited by Alcendor (2021) for this lack of vaccination was historic mistrust in the government, often due to historically racist mistreatment.
As a Tennessean university student during this time, it was evident from conversations, social media discourse, and classroom discussions that students from more rural communities were more likely to subscribe to beliefs circulated by right-wing media promoting misinformation and distrust about the vaccination and the pandemic itself. Thus, generational fears were reinforced, and those rural communities served as reservoirs of reinfection for COVID-19. It is also important to note that while many people in these communities are demographically different, they share community spaces for discourse and have the potential to be influenced by group thinking and social influence (Radinsky & Tabak, 2022). Many individuals’ personal mistrust comes from racial mistreatment that has compounded over generations, like the historic abuses in the Tuskegee trials or the autonomy-violating experiments of Marion Sims, from the U.S. government and its medical institutions (Nuriddin et al., 2020). Thus, although many people may not feel negatively about the vaccination, they may not feel the same sense of urgency that others feel in different regions, and they are more likely to come in contact with circulated fears and reasons for distrust.
In Appalachia, lack of government support in maintaining hospital services and staff led to a swift decrease in care capacity. Because rural communities have significantly fewer medical providers, it was decided that hospitals would stop non-emergent services during the pandemic to conserve resources and prevent unnecessary infection (Welch, 2023). This decision resulted in the layoff of many providers who could not provide pandemic services, further decreasing rural access to income and healthcare. While I was working as an emergency room volunteer in Knoxville, Tennessee, and a pharmacy technician at a large retail pharmacy, it was clear that many healthcare providers felt tremendously burdened by the increase in their responsibilities and harbored resentment towards legislators who were removed from the healthcare practice yet governing their work. Despite being essential workers who were vaccinating, testing, and providing medications for COVID-19, our employers were not providing increased wages to account for hazards or new roles. Despite many pharmaceutical corporations making significant gains from government subsidies, that money was not being distributed to employees, which follows a neoliberal approach to profits. Neoliberalism thrives off the exploitation of laborers, and its functionality does not include providing fair wages or equitable distribution of wealth (Peksen & Blanton, 2017). Additionally, pharmaceutical companies make more income from selling testing kits, medications, and supplemental health products when more people become infected. The lack of available healthcare in the presence of such massive profit generation seems nonsensical but it serves to highlight the ways in which structural oppression benefits the few at the expense of the many. It also clearly demonstrates the ways in which intersectionally oppressed communities may face exponentially more barriers to health and wellbeing during times of crisis (Fortuna et al., 2020).
Thompson Bastin and colleagues (2021) recently conducted studies to survey the shifting roles of clinical pharmacists who already benefit from comparatively higher wages, but there has been significantly less interest in the dissatisfaction of lower-ranking healthcare workers like hospital technicians and pharmacy technicians. From my communications with other hospital technicians, they were being asked to shift to completely different roles regularly without training or changes in pay under threat of being fired. It is under these conditions of exploitation and perceived replaceability that healthcare workers were expected to perform while massive corporations were obtaining government funds and generating profits.
Extensive scholarship coming out of the COVID-19 pandemic has described how governmental responses to COVID-19 interact with, and reinforce, neoliberal ideologies (Nunes, 2020; Ryan, 2020; Saad-Filho, 2020; Stewart et al., 2021; Šumonja, 2021). My experiences of COVID-19 in the United States demonstrate how responses to a health care crisis under capitalism reflect political ideologies but my experiences outside of the American South demonstrate regionalist misconceptions of oppressed populations that inappropriately homogenize the political ideologies within the region. In the United States, varied policies across states led to discordant public health efforts and neoliberal economic practices further stressed socioeconomic stratification. This variation paired with capitalist exploitation of laborers, nationally and abroad, contributed to the continued structural violence against people of color, elderly populations, and many other populations that already suffered from disparate healthcare outcomes (Johnson et al., 2023; Krupal & Sadural, 2022). While infection and mortality rates varied drastically between regions of the United States and other countries, it is important to recognize and problematize the shared trends of populist beliefs and capitalist pushes to return to normal economic function despite risks to the general working population of North America. It is also crucial to further examine those communities with higher infection rates and work to truly understand what is causing those disparities rather than accepting regionalist ideas circulated by mass media.
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