Johnson S. COVID-19 and workplace policy re-imagined: what is health and safety without equity? Harvard Public Health Review. 2021; 33.
In 1968, the height of the Vietnam War, approximately 14,000 Americans died in combat. That same year, an additional 14,000 American lives were lost at work —on the job (Cohen & Gunther, 1980). Few health and safety acts existed, however, they did very little for work-related injuries and provided workers no legal protection. When workers organized strikes against these harsh conditions, they were broken up by their employers and sometimes by police (Durrin & Hayman, 1980). Ensuring a worker’s right to a safe and healthy workplace was an area of great contention in the US for a long time. As a result, millions of US workers have lost their livelihood to an array of occupational hazards, such as inhalation of harmful substances (e.g. cotton dust), exposure to loud noises (e.g. hearing loss) and chemical explosions. Fortunately, the days of facing preventable risks on the job came to a screeching halt in 1970, when congress passed the historical, Occupational Safety and Health Act (OSHA).
Arguably, the second most important turning point for US workers was the ‘right to know’ —courtesy of the Hazardous Communications Standard (Hylko, 2006). Prior to the implementation of OSHA, safety education stressed that most accidents were the workers own fault, even though many tragedies were not a result of a worker’s carelessness. Access to safety information and protocols enabled employees (and the public) to be mindful of hazardous materials and how to use these substances safely, circumventing risk for work-related injuries and exposures nationwide (Robins et al., 1990). Similarly, in Canada, the 2008 Workplace Hazardous Materials Information System (WHMIS) was created to quell the rising tide of work-related injuries and fatalities during the industrial era. Now part of many training programs, employers use WHMIS to educate their employees about product identification, classification but most importantly, how to protect themselves from harm (DeGuzman, 2012).
In hindsight, the US labor force has come a long way. Still, how can one piece of legislation, drafted over 50 years ago, remain relevant in the modern workplace? Amid COVID-19, ensuing job losses, COVID-related deaths, and low prioritization of essential workers for vaccination, have brought about a renewed emphasis on empowering employees, the social determinants of health, and an urgent need for equity-informed workplace policies. In the 70s, OSHA’s greatest concern may have been to protect working citizens regardless of industry size or risk. Today, health and safety legislation is challenged to protect employees regardless of social location. With full consideration of multiple social issues (e.g. structural racism, mental health stigma, gender equality etc.) and rising public health threats (e.g. the emergence and re-emergence of infectious diseases), OSHA can re-write history once again.
The labour market has changed drastically over the last 30 years as employers seek to compete in the global economy (Landsbergis, 2012). Globalization has automated supply chains, boosted foreign direct investments, and scaled economies to sizes never imagined before, fuelling ongoing demand for knowledge-sensitive and tech-savvy professionals (Saunders, 2108; Kuepper, 2020). Even the racial/ethnic minority portion of the US labor force has seen drastic transformation: according to recent 2019 labor department data, unemployment rates for Hispanics and African Americans hit a record low (Fitzgerald, 2019). However, at the backdrop of our economic prosperity lies a long and dark history of systemic racism and discrimination, which have reinforced occupational health disparities seen among communities of colour today.
During the 2008 economic crisis, the World Health Organization (WHO) Commission on Social Determinants of Health published a report detailing the impact of social determinants on health inequities. As the report reads, “poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics” (WHO, 2008). Systemic racism is at the core of stark and persistent racial disparities in jobs, wages, benefits, and every other measure of economic well-being etc., that impact the social determinants of health, yet it wasn’t mentioned once throughout the report (Park & Sandefur, 2003; Grzywacz, & Quandt & Arcury, 2008; Ruckert & Labonte, 2017). For example, Silicosis has led to significant morbidity among automotive foundry workers. Just as Rosenman et al. (1996) found that black workers had greater exposure (mg/m3) to silica, despite having a similar duration of work as white workers, likewise, it is unspringing that communities of colour account for over 80% of cases across North America, when we know that decades of systemic racism has concentrated people of colour into ‘essential’ work often involving high human contact and inadequate access to personal protective equipment (PPE) (e.g. bus driving, postal service etc.) (Public Health Ontario, 2020; The Lancet, 2020; Rho, Brown & Fremstad, 2020).
Under OSHA, employers are responsible for providing workers a safe and healthy workplace. Under lockdown, that has looked like mass installations of plexiglass barriers, strict physical distancing rules and mandatory mask wearing in communal work areas —but this is only the tip of the iceberg. While these public health strategies are aimed to disrupt viral transmission, these measures do not tackle socio-economic mechanisms such as occupational segregation, black-white wage gaps, or discriminatory hiring practices that disproportionately funnel people of colour into occupations considered high-risk for infection. For OSHA to truly target work-related health disparities, social justice and health equity must be at the center of workplace standards (Garcia et al., 2020).
In many countries, ensuring a worker’s health and safety is high priority, as it is fundamental to human dignity, benefits the economy and strengthens public health solutions (Quinn, 2003; Leong et al., 2017), however, mental health has become an increasing concern for employers around the world. Particularly in the EU, a higher portion of its national budgets are pouring into adequate infrastructures and services for mental health. (WHO, 2003). Epidemiological data comparing changes in health status before and after a life altering event (e.g. an economic recession) are consistent and report negative associations with mental health and increased mental health problems among workers (Frasquilho et al., 2016). For example, a longitudinal study from Greece showed a significant increase of mental health issues among individuals who’d lost their jobs during the 2008 economic crisis (Drydakis, 2015). Reeves et al. (2018) found that ‘economic suicides’ gripped most European countries after the onset of the recession in 2009. Conversely, the EU and member states’ national and regional governments have been working to develop EU quality frameworks and the relevant resources to guide psychosocial occupational safety and health risks management (European Health Parliament, 2020).
Certainly, a global health pandemic can be a significant source of uncertainty and crippling anxiety, placing virtually every working citizen at increased risk for psychological injury. However, there are certain professions impacted harder than others: suicide rates are highest among physicians and health care workers (Duthiel et al., 2019)
Stress in medical practice is nothing new, although key stressors such as role conflict, emotional labor, intense training, and a hostile work environment certainly magnify mental health issues for health care workers (Pandey & Singh, 2015; Shah, 2017: Miedema et al., 2009; Familoni, 2008). Nonetheless, previous viral outbreaks have taught us that additional stressors such as isolation, increased contact with infected patients, and reduced community support, only increase psychological risks (Wu et al., 2009; Maunder et al., 2006; Gulati & Kelly., 2020). Post-traumatic stress disorder, fatigue, depression and anxiety are common mental health disorders among physicians (de Jong, Nieuwenhuijsen & Sluiter, 2016). Frequent night-shifts could be argued as the main driver behind the prevalence of sleep disorders among health care workers, but this only furthers the point that prompt action from OSH (and other leadership in health and safety) is necessary to help reduce all known mental health risks (Henderson, Evans-Lacko, & Thornicloff, 2013; Kim et al., 2018. Unquestionably, the catastrophic impact of COVID-19 on the healthcare industry serves as a mighty wakeup call for OSH resources to expand into mental health services. Evidently, our current healthcare systems are unable to effectively help the helpers (Lai, 2020; Muller et al., 2020). Should OSHA fully support public health efforts to reduce mental health stigma and increase access to mental health care for struggling professionals, the course of history in healthcare would be forever changed.
Over the last 50 years, women’s participation in the labor force has increased dramatically, causing widespread changes in job structures, social atmospheres, and human resource policies (Egri & Ralston, 2004; Lyons et al., 2005). For example, in 2019, the Canada Labour Code granted nursing breaks for mothers for all federal employees (Stam and Page, 2019). But for women living in countries with more stringent policies on women’s economic mobility, their hurdles have less to do with maternal benefits, and more to do with literal safety –both on the job and on the way to work (Carnegie Council, 2018). Around the globe, COVID-19 has forced health care workers to confront a similar reality: by September 2020, approximately 7,000 health workers worldwide died from a lack of basic protection (Amnesty, 2020).
Everyone deserves to be safe at work —this is the single most important tenet of injury prevention. But for the many women who rely on PPE to do their jobs, this fundamental principle does not corroborate with their daily realities on the frontline.
Owing to OSHA’s 1999 report which described ‘ill-fit PPE’ as a health and safety hazard for women, there are now hundreds of PPE and products designed with women in mind, however, access is often limited (Walker, 2010). Conversely, the male-female divide on appropriately fitting PPE is not isolated to the US: twenty-nine percent of women in the UK have PPE that fit despite decadelong amendments made to UK’s occupational regulations (TUC, 2017). For certain population groups, the consequence can be fatal: women make up approximately 77% of the National Health Service (NHS) workforce, but nearly half are comprised of population groups with the highest risk of death by COVID-19 (e.g. Black, Asian, and Minority Ethnic groups) (Wilkinson, 2020; Barr et al., 2020).
Overall, the guidelines are clear, and the policies exist. The problem is, few employers enforce them. Given what we know about COVID-19 morbidity and mortality, wearing a mask that’s too big or loose eye shields is a matter of life and death for vulnerable population groups. Understandably, men overrepresented hazardous industries during the industrial era, therefore creating PPE based on the biometrics of male bodies was standard. However, with more women in the labor force now more than ever before, including non-traditional jobs (Kennedy, 2020, it’s difficult to parse our historical legacy of deprioritization and devaluation of women and their work from PPE shortages in the exact same industries they dominate (e.g. healthcare).
Enough evidence exists to conclude that discordance exists between occupational safety standards and public health targets. Hazardous materials/waste, fire drills, spillage etc., have received substantial public health attention over the decades. Currently, infectious disease outbreaks are on the rise; poverty is skyrocketing; and consequently, health disparities are widening at an unprecedented rate (Bloom & Cadarette, 2019; Sandoval, Rank & Hirschl, 2009). So long as improving workplace protocols remains a top priority to OSH professionals and State agencies, then experiences of society’s most marginalized workers must be central in the work.
Firstly, workers in hazardous industries require paid sick leave benefits, as it could be considered a prevention strategy for overdose deaths at work. Throughout 2020 our nation has been stifled with a crisis on top of a crisis: COVID-19 and the opioid epidemic. Given that construction has one of the highest injury rates, workers are often prescribed opioids to treat the pain (Ahmad, Rossen & Sutton, 2021). In 2017, the Department of Public Health (Massachusetts) released a disturbing report showing that unintentional overdose deaths were highest among workers in occupations with lower availability of paid sick leave and lower job security (e.g. construction) (Mass.gov, 2019). Lack of paid sick leave is a public health risk deserving of financial penalty.
Paid sick leave should also be offered to essential workers. Absence of a public framework for basic social protections, has ultimately prepared Blacks, Hispanics, single mothers, low-wage earners —workers usually without the protective benefit of hazard pay/paid sick leave— for severe economic vulnerability and health disadvantage (Mun & Brinton, 2017; Bartel et al., 2019). Indeed, Black women are in the most precarious position, as they sit at the intersection of gender and racial lines which compromise the social determinants of health. Consequently, their lives, and occupational experiences are vital in shaping and advancing health equity for future policy solutions and OSH guidelines moving forward.
Lastly, OSH guidelines need to expand on mental health and broaden its scope of work-related injuries. The impact of mental illness on individuals, families, and societies are devastating, however, suicide and drug overdoses (among other fatalities) are not routinely addressed by OSHA (Mass.gov, 2019). Business leaders assert that employee assistance plans (EAP) are highly underutilized because people are unaware of them (Miller, 2019; Gunlock, 2020). Just as OSHA’s overwhelming support for a worker’s ‘right to know’ about hazardous materials benefit the workforce of that generation, today’s workers could equally benefit from OSHA supporting a workers right to know about the various mental health services and support provided by their employers.
As we can see, health and safety regulation is deeply intertwined with economics, gender equality, race relations, public policy and social justice. Perhaps looking at health inequities as a workplace injury, rather than a statistical outcome after-the-fact, may help upend discriminatory and punitive workplace structures that have long contributed to economic and social vulnerability for women, racialized, and low-wage workers (Bentley & Barr, 2018).
COVID-19 has tasked policymakers with the challenge to not only view a worker’s health and safety as a public health good but to also develop and enforce policies that reflect this perspective. Otherwise, workers will continue to go to work even when they are sick, increasing the opportunity for disease transmissions to affect everyone else (Lovell, 2004). Such is the paradox of inequity: even the well-off are worse off than they would be if systems were more equitable (Berkowitz, Cene & Chatterjee, 2020).
Of course, building equitable systems requires collaboration. Our efforts ought to involve more than just the traditional players, and pivot towards an intersectional approach to best address occupational inequities at national, state, and local levels (Institute of Medicine, 2002). Most importantly, to reconnect OSHA and public health (and all other stakeholders) in a meaningful way, health equity must be the goal. The macroeconomic impact of lockdown has made it quite clear that essential workers are just that —essential. It’s about time that their health and well-being are valued and protected as such.
Simisola Johnson received her BSc in psychology and neuroscience at the University of Toronto and is currently completing a certificate in narrative medicine. Her main interests include politics, astronomy, ethics and global health challenges but writes primarily about public health issues. Simisola’s article “Globalization, urbanization and COVID-19: Implications for a World all too Connected,” is featured in the Harvard Public Health Review.