COVID-19 has uncovered and multiplied health workforce equity challenges across the US. In the early days of the pandemic, healthcare workers faced incredible personal risk from an unknown, highly contagious, deadly disease. Insufficient personal protective equipment (PPE) and reprimand and dismissal by employers for speaking out worsened this risk.
As waves of COVID-19 swept across the country, hospitals were overwhelmed and understaffed, struggling to find physicians, nurses, respiratory therapists, and others. The crisis in hospitals also highlighted the essential role and risks born by nonclinical workers. They are essential staff who check-in, transport, clean, feed, and provide security so that patient care can continue.
The Invisible Workforce
Shortages occurred across the health workforce, especially in the neglected corners of health care. As nursing homes became hotspots for COVID-19, the direct care workers (personal care aides, home health aides, and nursing assistants) became visible. This workforce of largely women, people of color, and immigrants already worked challenging jobs at very low wages. COVID-19 increased the stress of this work. It also brought to light the need to address social factors like childcare, safe transportation, and living wages to continue to work.
Public health contact tracers are another often unseen health workforce. COVID-19 made this workforce much more visible as communities scrambled to recruit and train greater numbers. States struggled to do this and the effects of the chronic underfunding of public health became apparent as COVID-19 infections and deaths grew. The essential partnership between medicine and public health was found lacking.
Violence, Discrimination, Burnout and the Loss of Health Workers
Workplace violence and other attacks against healthcare workers increased during COVID-19. The experience of racism did too. Health care workers faced, for example, discrimination related to anti-Asian sentiment associated with the virus. The racial equity movement, driven by police violence and clear racial/ethnic disparities during COVID-19, also generated needed agitation in healthcare to address health disparities and diversity, equity, and inclusion. The pandemic reminded us how large parts of our health workforce are people of color and often women. And they are part of the very communities deeply impacted by the virus. This is particularly true in lower-paid healthcare jobs
The stress of difficult work, personal risk, workplace violence, and moral injury has led to a rise in burnout amongst health workers. The sum of this is the loss of health workers. As of August 2021, the CDC estimates there have been over 1,600 healthcare worker deaths. Healthcare workers are leaving patient care and closing practices due to financial strains. The loss of these workers will further increase the strain on those remaining, creating a literal death spiral. Evidence shows, for example, that nurse staffing shortages and shortages in the primary care physicians and public health resources are associated with greater mortality.
Improving Health Workforce Equity
The pandemic has created an urgency to protect our health workforce and enhance their ability to effectively care for the public during a pandemic and beyond. A recent commentary in Medical Care, which we contributed to, lays out six policy goals for health workforce equity:
- More diverse health workforce that reflects communities. A diverse workforce also provides the diversity of perspective needed to deliver high-quality health care.
- Social mission in health professions education to advance health equity. Institutions can do this through their missions, programs, leadership, faculty, and graduates.
- Better distribution of the health workforce aligned with population needs. This includes geographic distribution of high need specialties like primary care and mental health.
- Greater focus on vulnerable patients including populations who are uninsured, covered by Medicaid, LGBTQ+, with disabilities, or experiencing homelessness.
- Orientation to the root causes of health disparities. This includes new models of medical care to address social determinants of health, and policy reforms to advance health equity.
- Safer and fairer set of working conditions for all health workers. Conditions that ensure physical and psychological safety, reduce workload and administrative burdens, provide living wages and work supports, and address moral injury from working in unjust systems.
Our nation’s poor performance in all six of these health workforce equity areas predates COVID-19. We should no longer neglect it. Without better policies and programs, these long-standing issues and the additional loss of health workers will inevitably further impact already vulnerable communities – those communities already struggling with healthcare access and workforce shortages.
Health worker wellbeing is inexorably tied to access, quality of care, and outcomes. As a country, we are responsible for the extent to which health workers have the competencies, opportunities, and courage to practice in the places and in the ways that enhance health equity.
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