Health Inequity and the Unfair Impact of the COVID-19 Pandemic on Essential Workers

The COVID-19 pandemic has laid bare our country's widespread economic and health disparities—most acutely in large, urban cities. Decades of systemic and institutional racism in policies and practices, such as redlining and biased lending policies, perpetuate inequity, leaving communities of color, specifically Black and Latino communities, vulnerable to worse health outcomes. In New York City (NYC), Black and Latino individuals are approximately twice as likely to be hospitalized and die of COVID-19 as White individuals.[1] Although underlying health conditions contribute to these higher COVID-19 morbidity and mortality rates, individuals from Black and Latino communities are also more likely to be essential workers, limiting their ability to physically distance and increasing their exposure risks. Recent work supports the concept that exposure opportunity is driving racial/ethnic disparities in COVID-19 outcomes.[2]

Black and Latino individuals are overrepresented in food- and customer service–oriented occupations and must put themselves at risk for their personal job and financial security and to keep the economy going by providing critical services. In NYC during the initial months of the pandemic, data gathered by the NYC Department of Health and Mental Hygiene showed that 26% of Black and 22% of Latino adults reported exclusively working from home, compared with 44% of White New Yorkers. Black and Latino New Yorkers were also more likely to use public transportation than were Asian/Pacific Islander and White adults during the peak of the pandemic (New York City Health Opinion Poll [NYC HOP] wave 7, fielded from March 26–March 31, 2020, unpublished). Furthermore, at a national level, Black and Latino individuals are more likely to live in multigenerational households. Thus, their continued exposure because of their essential work roles placed both individuals and their families and loved ones at increased risk of infection. These structural risk factors leave essential workers, and the communities of color they are part of, unfairly vulnerable to COVID-19.

Fear and mistrust—coupled with lack of information—may result in delays in seeking necessary health care among essential workers and their communities. Immigrants, who are also overrepresented in the essential workforce, face rising anti-immigrant rhetoric in the United States, which escalated in the months preceding the pandemic. The federal public charge rule, implemented in 2019, restricted access to governmental services, including housing assistance, nutritional support, and other public assistance to residents without documentation. Mistrust of the health community may also lead to delays in seeking health care. In the Black community, mistrust stems from years of treatment bias, neglect, and unethical practices by clinical providers and biomedical researchers. Further inequities exist by age, race/ethnicity, education, and income in access to the technology necessary to access information and resources that can protect and support people through times of crisis. These factors all may play a role in the impact of COVID-19 on the essential workforce.

Essential workers are often the lowest paid: they comprise almost half of the workers that make less than $15 per hour.[3] Low-wage workers are more likely to have limited sick leave benefits and inadequate health insurance, leaving them to choose between working while sick or earning income. Black and Latino essential, non–health care workers were four times as likely to report no health insurance coverage as their White counterparts.[4] In NYC, residents from poorer neighborhoods reported avoiding care for symptoms related to COVID-19 because of potential cost (NYC HOP wave 8, fielded from April 16–April 23, 2020, https://on.nyc.gov/3y8WYhM). These disparities exacerbate the impact of COVID-19 and are unjust, especially considering the lifesaving role of essential workers during the pandemic.

Against this backdrop, the public health response to COVID-19 has been complicated and uneven. Early in the pandemic, there were uncertainties about virus transmission and limited COVID-19 testing. Mitigation efforts, including mask usage and social-distancing guidance, evolved throughout the initial phase of the pandemic, and protective supplies were limited. As stay-at-home guidance was implemented, essential workers had to navigate going to work safely amid these changing circumstances. Furthermore, efforts to obtain complete data on COVID-19 cases, hospitalizations, and deaths were hampered by missing or limited data on race and ethnicity and occupation. Such data limitations restricted the ability to fully characterize the relationship between essential work exposure, COVID-19 transmission, and the adverse outcomes.

The complicated COVID-19 vaccine rollout has presented similar challenges for essential workers. Although older adults were prioritized to reduce deaths and serious health outcomes, the prioritization of essential workers was less consistent across the country. The initial limited vaccine supply combined with high demand for vaccine appointments has resulted in disparities in vaccination rates. As vaccination is now more widely available and more older adults are vaccinated to prevent the most serious health outcomes, essential workers should continue to be prioritized in vaccine access and uptake strategies.

As policymakers and public health practitioners work to reduce the long-term impact of the COVID-19 pandemic, equity and the role of the essential worker should be front and center. Some lessons can be learned from the NYC response: in NYC during the initial phase of the pandemic, algorithms were developed to ensure that hospitals workers had equitable access to personal protection equipment. Wraparound services, including access to health care providers, hoteling, mental health support, and food support were provided to COVID-19–positive residents who were not able to social distance, many of whom were essential workers. Additionally, localized approaches were used to ensure that COVID-19 testing and other resources and supportive services were focused on the hardest hit communities. Engagement with community organizations, many of which serve essential workers, has also been critical to promoting the public health messages and equitable distribution of vaccine.

The pandemic has demonstrated a reliance on essential workers, but the wage gap does not reflect the value of their work. Early in the pandemic some companies provided hazard pay as a temporary form of relief. The proposed HEROES Act (Health and Economic Recovery Omnibus Emergency Solutions Act) was intended to make hazard pay for essential workers a federal law. Even with the availability of hazard pay, the federal minimum wage rate, which has not changed since 2009, needs more sustained change. Recent efforts to include raising the federal minimum wage to $15 per hour as part of the COVID-19 relief bill were defeated. Changing the federal minimum wage to at least $15 per hour would allow many essential workers across the country to earn a living wage.

Beyond hazard pay, essential workers must also have access to affordable health care, paid sick leave, and safe and healthy workplaces. Although the HEROES bill outlined provisions for hazard pay, the Essential Worker Bill of Rights goes further by extending provisions to include personal protection equipment, COVID-19 testing, health care, paid leave, and hazard pay. The Biden administration's recent executive order[5] and the COVID-19 relief bill may offer more support and protection to essential workers. However, state and localities should continue to pursue protections for the well-being of their essential workforce.

The dual pandemics of COVID-19 and racism have exposed unacceptable inequities in our country. Essential workers reflect the communities in which they live, and they have experienced the brunt of the COVID-19 pandemic. As a society, we must continue to ensure adequate protections and address pay equity. As a public health community, we must prioritize and integrate equity into our programming and planning for COVID-19 and other public health threats to ensure that essential workers and their communities are protected.

I thank Hannah Helmy for her thoughtful review and feedback and Julia Morrill for providing helpful edits.

The author has no conflicts of interest to declare.