All Health Care Workers Are Critical Workers, But Not All Critical Workers Are Health Care Workers

by Emily Johnson and JP Leider


Meditations on the MPH

Minnesota, like much of the United States, is in the midst of a COVID surge. While previous surges have stressed our resources, article after article after article highlights that our health care systems are at a breaking point. As the vaccine rollout is being discussed and (hopefully) soon finalized nationwide, it is worth revisiting why critical workers at high risk of occupational exposure to COVID might deserve priority access to vaccines and other therapeutics. It’s also worth discussing that, while health care workers take on enormous risk for society, they aren’t the only ones to do so. We must prioritize access for other critical workers in high risk settings (CWHRS), too. Over the past couple months, we’ve been looking at occupational COVID case data from Minnesota, and believe that empirical data should inform broader ethical and political discussions about CWHRS prioritization and that the notion of CWHRS includes, but is not limited to, health care workers.

As part of this investigation, we coded 33,145 de-identified occupational COVID cases provided by the Minnesota Department of Health, using O*NET job families to manually sort case records. We also identified “critical workers” from federal guidance and the Governor’s springtime Executive Order. All in all, from 1/1/2020 to 8/15/2020 we had 25,055 codable cases catalogued in Minnesota, ages 14-64. We’re excluding cases 65 and older and younger than 14 to promote comparability.

In short, critical workers represent a disproportionate number of COVID cases, and race- and ethnicity-based disparities are profound. It’s important to know that roughly 72.5% of Minnesota’s workforce is deemed “critical” under the governor’s executive order. In the occupational data, 85.6% of codable cases involved job families with a high proportion of critical workers. While not all critical workers have high occupational risk of exposure to COVID – especially the growing number that can telework – many do. In the early months of the pandemic, critical workers in Minnesota were affected by COVID-19 in much higher numbers  than non-critical workers (Figure 1). Health care workers are disproportionately affected relative to workers in many other industries. However, closer analysis of COVID-19 occupational data from the Minnesota Department of Health reveals that there is a sizeable risk difference between categories of health care workers, as well as critical workers in other sectors that also potentially deserve attention and prioritization for resources.

Three categories of workers stand out for their disproportionate share of COVID case counts compared to their representation in the state workforce: Production, Health care Support, and Personal Care and Service workers (Figure 2). Records show substantial racial/ethnic disparities because these job families are composed of disproportionately high numbers of Latinx and Black workers.

Production workers, such as those employed in manufacturing and food processing, appear to face the highest relative risk compared to workers in other sectors in Minnesota, with 200% higher representation in the occupational case data set than in the MN workforce overall in March through August. Likely, this elevated risk has continued or increased in months since.

Healthcare Support workers include nursing assistants and resident assistants in long-term care facilities and group homes, and these workers also face an outsized risk of roughly 167%. This is notably higher than the additional risk faced by Health care Practitioners and Technical workers (eg, physicians, nurses, health care technicians) of 29%. Personal Care and Service includes a wide range of job functions including childcare, hair stylists, and golf course and fitness center employees (Figure 3). Among these workers, childcare workers are the only ones designated as critical, but this represents 42% of the job family.

Implications for Racial/Ethnic Disparities

The unequal distribution of COVID-19 cases across job families exacerbates racial and ethnic disparities because the job families with the highest case rates are made up of a high percentage of non-white workers. Together, Black and Latinx Minnesotans constitute about 13% of the age 14-64 state population. However, they make up 62% of COVID-19 occupational cases for Production, 54% of cases for Healthcare Support, and 38% of cases for Personal Care and Service.

Black women appear to be disproportionately impacted by occupational hazards, as they make up 3.4% of the 14-64 MN population but 34% of the reported Health care Support COVID-19 cases and 19% of the Personal Care and Service cases. Similarly, Latino men face outsized occupational hazards, as they make up 3% of the 14-64 MN population but 27% of the Production cases.

Crude case count per 100,000 people ages 14-64 for Latinx and Black workers in Minnesota were about 6.5x and 4.6x higher (respectively) than the rate for White workers through 8/15/2020 (Figure 4) in the data.

Furthermore, the timing of case onset varies by job family and by race/ethnicity, with Black and Latinx workers experiencing the first peak in late April. White workers peak in July during Phase 3 of Minnesota’s reopening plan (Figure 5). The variation in onset timing is significant because very little was known about COVID-19 in the earliest months of the pandemic, and treatment guidelines and therapeutics have been developing over time.

Implications for vaccine and therapeutics prioritization

From the beginning of the pandemic through mid-August (the time period for which data are currently available), COVID-19 infections were observed in occupations disproportionate to the number of workers in each field in the state of Minnesota. The case rates for workers in Production, Health care Support, and Personal Care and Service were particularly high, likely due to working conditions that require close contact with others and inadequate PPE.

These groups faced substantial risk of exposure to COVID by virtue of the work they took on that benefits society. Simply put, they are instrumental to COVID response and social functioning, and also owed protection from all of us in society because of the risk they take on to provide services to us (so-called “duties of reciprocity”). Even now, when community spread is so prevalent that many or most workers might be getting COVID outside of the job, there is no question that we are worse off when fewer critical workers, especially health care workers, are on the job because of COVID.

It’s for these reasons that critical worker prioritization is showing up in preliminary vaccine guidance and other frameworks being considered across the US. Plans to protect critical workers might also include better PPE, improved physical and safety conditions in the workplace, more distancing, better ventilation, and paid sick leave, among others. Each class of protection and prioritization is owed to critical workers in high risk settings.

Yet, figuring out how to prioritize access such that the public still has a fair shot at these resources while recognizing and rewarding the risks that critical workers take on in the instrumental role they play is a challenging balance. It can be controversial. However, what should not be controversial is that just as health care workers deserve priority, so too should others who face elevated occupational risk of exposure to COVID by virtue of the work that they do, such as food production and childcare workers, among many others. As we said in the title, all health care workers are critical workers, but not all critical workers are in health care.

Interested in learning more about our methods?

Data from case reporting were collected by the Minnesota Department of Health and deidentified records were provided to the author team. Occupational information for each case was primarily captured through text fields such as “work setting” and “employer.” Cases in the data set were assigned to one of 23 ONET Job Families based on text information provided by respondents. Some cases had a clear role description (ie, Physical Therapist) but others provided only Employer information (ie, works at Target) or Work Setting (ie, Warehouse). Job Family designation is a “best guess” based on available information. Roughly 19% of data is unclassified due to lack of information. The critical worker flag is primarily based on detail provided about job function in the text entries. For cases in which a role was not clearly specified, the flag is determined by the ONET Job Family that the worker falls in. ONET job families in which 75% or more workers in Minnesota statewide have occupations designated as “critical” by CISA or the Governor’s Executive Order are marked as critical.

This analysis has a few key limitations. Approximately 20% of the data provided was not assigned an ONET Job Family due to limited information provided. It is possible that these cases are unevenly distributed across job families, which may impact the results. Additionally, job family assignment was based on available information, which was mostly free form text entries. Over 50% of the cases in the data set only contained information in the “Employer” field, so a job family was assigned based on the industry of the employer rather than the job function of the individual. This may overstate the true population of workers in some job families such as “Production” or “Food Preparation and Serving Related” and understate the population of workers in job families such as “Management” or “Business and Financial Operations.”

Acknowledgements

The author team would like to acknowledge the Minnesota Department of  Health for their provision of the deidentified occupational case data. The team would also like to acknowledge Deb DeBruin for her thoughtful comments on this post. Johnson was funded through the Master of Healthcare Administration program as a Graduate Research Assistant.

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Emily Johnson is a student in the Master of Healthcare Administration program and the University of Minnesota School of Public Health. Prior to joining the program, she worked in healthcare consulting with a focus on data analytics. She received her undergraduate degree in Economics from Washington University in St. Louis.

Author Profile

JP Leider
Jonathon P. (JP) Leider, PhD, is an independent consultant in the public health and health policy space, as well as a Senior Lecturer at the University of Minnesota and Associate Faculty at the Johns Hopkins Bloomberg School of Public Health. He has active projects and collaborations with foundations, national public health organizations, public health researchers and academics, and public health practitioners. His current projects focus on public health systems, the public health workforce, and public health finance. He holds a PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health.