In an effort to flatten the curve and promote containment of the novel coronavirus (COVID-19), safety precautions, including stay at home measures, have been enacted. However, several members of the lower-waged workforce, such as healthcare support staff, bus drivers, and sanitation workers, referred to collectively as “essential” workers, were deemed exempt from such policies; over 90% of workers who are in the bottom 25 income percentile do not have the ability to work from home.[1] In addition to mental health challenges associated with serving during COVID-19, the experiences of essential workers of color is complicated by the recent acts of structural violence against black bodies, a microcosm of the pandemic of racism that has plagued the U.S. for 400 years. Consequently, it is worth framing the discussion of mental health challenges and stressors of essential workers during COVID-19 in the context of identity.

How Race and Class Complicate the Mental Health Challenges Faced by Essential Workers during COVID-19

It is critical to highlight the intersectionality of race and class, and how people of color are disproportionately represented in low-wage, high-risk occupations deemed essential. Over 53 million workers aged 18 to 64 in the U.S. have median annual earnings of $17,950, and both Black and Latinx workers are overrepresented in these low-waged positions.[2] Over 6.5 million U.S. healthcare support workers, including home health aides, medical assistants, and technicians earn less than the national median wage and also often lack basic workplace benefits.[3] More specifically, over 50% of these workers do not have paid sick leave and over 75% of them do not have access to paid personal leave.[4] Thus, in spite of the fear of risking their lives and the health of their family, these members of the workforce continue to report to work just to survive.

Essential workers are also often low-waged people of color[5] whose duties require them to be in close physical proximity with others.[6],[7] For example, nursing home employees, whose median pay for nursing assistants was $29,640 in 2019,[8] work in spaces that have been devastated by COVID-19.[9] As a result, these essential workers have witnessed their elderly patients become sick and pass away with no time to grieve because of limited to no paid time off or sick leave. Similarly, environmental service workers at hospitals who disinfect hospital rooms occupied by COVID-19 patients, as well as sanitation workers who handle everyone’s trash, face new risks on a daily basis with limited access to personal protective equipment (PPE) or hand sanitizers.[10] Their work is saving lives, but the public rarely recognizes the importance and hardship of their work during the pandemic.

Emerging data has shown low-waged workers are struggling with stress, burnout, nightmares, and insomnia.[11] Facing stressful situations on a daily basis not only causes mental health problems (e.g., depression, anxiety, post-traumatic stress disorders),[12] but also physical health issues (e.g., high blood pressure, cardiovascular disease).[13] We however know much less about the status of mental health and wellbeing of low-wage, high-risk essential workers compared to higher-paid, licensed healthcare providers before and during the pandemic. Similarly, there is increasing evidence that COVID-19 is not the great equalizer; on the contrary, the racial/ethnic disparities observed in other health outcomes is also made evident in the current pandemic.[14] Consequently, low-waged essential workers of color are experiencing a disproportionate level of death and grief not only over clients, patients, and customers, but also over family members, friends, and other loved ones.

Recommendations for Policy and Practice

As mental health clinicians and public health researchers, we propose the following recommendations:

Expanding and diversifying the mental health workforce. National shortages of mental health workers existed before this pandemic began, and are projected to get worse over the next five years.[15] As the mental health of essential workers suffers, they must be practically able to access the mental health care they need. Thus, financial resources should be directed towards expanding the number of mental health professionals. There is a particular need to diversify the mental healthcare workforce. There is a strong body of literature supporting the need to increase the proportion of racial/ethnic minority providers as a means for promoting trust and culturally and linguistically competent care in the therapeutic relationship.[16] Thus, dedicating Federal funds towards the recruitment and retention of a diverse mental healthcare workforce is a key policy recommendation for addressing the acute and chronic mental health needs of low-income essential workers of color, as well as reducing health disparities.

Strengthening Employee Assistance Programs. Current resources, although much needed and helpful, tend to focus on mental health and well-being of clinicians.[17] Practical resources for healthcare support workers and non-healthcare essential workers are hard to find. Cost and stigma are the top barriers to mental health care access.[18] Employers and leadership should assess the mental health needs of employees, normalize help-seeking behavior, and expand access to free and confidential support and resources for their employees. Additionally, open dialogue about mental health will help lessen stigma towards mental disorders. This pandemic may be a turning point where we talk about mental health openly enough so people feel as comfortable seeking treatment for mental health and substance use concerns as they do for any other common health condition.

Utilization of peer-support systems. Healthcare organizations and leadership should consider creating and/or amplifying a peer-support system at work.[19] Peer support is a crucial element in meeting the increased needs of vulnerable essential workers. In order to help increase access and encourage use of mental health services, Mental Health First Aid (MHFA) training should be given to as many people as possible. Non-clinical professionals use MHFA to encourage help seeking behavior and identify signs of distress and mental health conditions. Expanding MHFA training to these essential workers can help reduce suicides and to make sure that they seek the care they are certain to need.15

We can anticipate a greater need for mental health services for essential workers—a need that will last beyond the duration of the current public health crisis. Taking care of people who have served us throughout this pandemic must be our top priority.

References

[1] U.S. Bureau of Labor Statistics. Economic News Release. Table 1. Workers who could work at home, did work at home, and were paid for work at home, by selected characteristics, averages for the period 2017-2018. 2019. Available at https://www.bls.gov/news.release/flex2.t01.htm Accessed May 4, 2020.

[2] Ross, M. & Bateman, N. Meet the low-wage workforce. 2019. Available at https://www.brookings.edu/research/meet-the-low-wage-workforce/ Accessed May 4, 2020,

[3] U.S. Bureau of Labor Statistics. Occupational Employment Statistics. Occupational Employment and Wages, May 2019. 31-0000 Healthcare Support Occupations (Major Group). 2020. Available at https://www.bls.gov/oes/current/oes310000.htm Accessed May 4, 2020.

[4] U.S. Bureau of Labor Statistics. Employee Benefits Survey. 2018. Accessed May 4, 2020. https://www.bls.gov/ncs/ebs/benefits/2018/

[5] Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). COVID-19 in Racial and Ethnic Minority Groups. 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html Accessed May 4, 2020.

[6] Levenson M. 11 Days After Fuming About a Coughing Passenger, a Bus Driver Died From the Coronavirus. New York Times. 2020. Available at https://www.nytimes.com/2020/04/04/us/detroit-bus-driver-coronavirus.html.Accessed May 4, 2020.

[7] Bhattarai A. ‘It feels like a war zone’: As more of them die, grocery workers increasingly fear showing up at work. Washington Post. 2020. Available at https://www.washingtonpost.com/business/2020/04/12/grocery-worker-fear-death-coronavirus/ Accessed May 4, 2020.

[8] U.S. Bureau of Labor Statistics. Occupational outlook handbook: nursing assistants and orderlies. 2019. Available at https://www.bls.gov/OOH/healthcare/nursing-assistants.htm#:~:text=The%20median%20annual%20wage%20for,was%20%2428%2C980%20in%20May%202019 Accessed June 15, 2020.

[9] Yourish KK, Lai R, Ivory D. One-third of all U.S. coronavirus deaths are nursing home residents or workers. 2020. Available at https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html. Accessed June 20, 2020.

[10] Ducharme J. ‘No One Mentions the People Who Clean It Up’: What It’s Like to Clean Professionally During the COVID-19 Outbreak. Time. 2020. Available at https://time.com/5810911/covid-19-cleaners-janitors/ Accessed May 4, 2020.

[11] Hammonds C, Kerrissey J. “We are not heroes because it is not a choice”: a survey of essential workers’ safety and security during COVID-19. 2020. Available at https://www.umass.edu/lrrc/sites/default/files/Western%20Mass%20Essential%20Worker%20Survey%20-%20May%202020.pdf Accessed June 15, 2020.

[12] Jackson JS, Knight KM, Rafferty JA. Race and unhealthy behaviors: chronic stress, the HPA axis, and physical and mental health disparities over the life course. Am J Public Health. 2010;100:933-939.

[13] Sturgeon JA, Arewasikporn A, Okun MA. The psychosocial context of financial stress: implications for inflammation and psychological health. Psychosom Med. 2016;78(2):134-143.

[14] Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. JAMA. Published online May 11, 2020.

[15] US Department of Health and Human Services. National projections of supply and demand for selected behavioral health practitioners: 2013–2025. 2016. Available at https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf Accessed May 21, 2020.

[16] McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs. 2008;27(2):393-403.

[17] Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

[18] Budhwani H, De P. Perceived stigma in health care settings and the physical and mental health of people of color in the United States. Health Equity. 2019;3(1):73-80.

[19] Hammerback K, Hannon PA, Harris JR. Perspectives on Workplace Health Promotion Among Employees in Low-Wage Industries. Am J Health Promot. 2015;29(6):384-392.