culture of health

with support from:

www.healthaffairs.org/briefs

health policy brief  june 2021

Work plays a key role in moderating the COVID-19 pandemic experiences
of Americans and in imposing economic and social costs on households.

Frontline workers, many of whom are considered “essential,” face dispropor-
tionate health risks as they weather the pandemic. At the same time, many
white-collar workers have transitioned to remote work, often while simul-
taneously caring for dependent children, leading to severe role strain and
work-life conflicts.

The often-dire consequences of the pandemic are stratified along race, gender,
class, and occupational lines. In this brief we explore how existing inequalities
at work across these same categories perpetuate inequalities in the toll of
COVID-19. Before the pandemic, many of those currently working in frontline
positions faced low wages, few benefits, and erratic schedules. (Note: All linked
references in this brief are also listed in supplemental exhibit 1.)

Many of these issues have only intensified during the COVID-19 pandemic.
We highlight the importance of—and inequalities in—on-the-job conditions
that affect viral exposure risk and fringe benefits such as paid sick leave and
the ability to work from home that allow workers to manage risk. We also
propose policy recommendations to lessen these inequalities during the
pandemic and for the service sector moving forward. We do not recommend
a return to prepandemic standards but, instead, a movement toward a better
and more equitable future for employees.

The COVID-19 pandemic has laid bare existing
inequalities in workplace exposure to
health risks and economic insecurity. Policy
action is needed to protect workers’ health
during the pandemic and to support worker
empowerment and equitable opportunities in
the future.

INEQUALITIES AT WORK AND THE
TOLL OF COVID-19

Key Points
» Workplaces shape risk for exposure to

COVID-19 through on-site safety practices,
including the provision and required use of
personal protective equipment, as well as
protective policies such as paid sick leave and
the flexibility to work from home.

» More than one in every five US workers has
no paid sick leave. Recent expansions of paid
sick leave coverage still exclude many workers.
Low-wage workers are far more likely than their
higher-paid counterparts to lack paid sick leave
but are the least able to afford to take unpaid
time off from work when ill.

» Women, people of color, and those of lower
socioeconomic status are the most likely
among all workers to hold frontline positions
that require in-person work and the least
likely to have paid sick leave. These groups
have disproportionately experienced the
negative health and economic consequences of
COVID-19.

» Women have been disproportionately affected
by job loss and the caregiving burdens arising
from school and care provider closures, with
consequences for their career opportunities,
economic security, and mental health.

» Governmental action is needed on several
fronts: to empower workers by raising wages
and providing universal paid sick leave, to
strengthen COVID-19 workplace safety
mandates and enforcement of workplace safety
standards via the Occupational Health and
Safety Administration, and to prioritize a safe
reopening of schools and childcare centers.

2health policy brief

culture of health

On-The-Job Exposure To COVID-19
Risk
A key Centers for Disease Control and Prevention
(CDC) recommendation for containing the COVID-19
pandemic is minimizing exposure to persons outside
of one’s household. The CDC advises avoidance of
indoor interactions because infection risk increases
in enclosed spaces, particularly during extended
periods. Many essential workplaces are thus high-risk
environments, bringing coworkers and consumers to-
gether indoors, with most work shifts lasting multiple
hours.

Fifty million US workers (34.5 percent of all workers)
are both frontline and essential workers, meaning
that they cannot work from home and their work is
essential to meeting basic population needs. In this
case, essential workers are those employed at a busi-
ness or establishment that “must stay open during a
public health emergency.” When nonessential workers
are included (for example, those in restaurants and
retail establishments that have chosen to remain

open as permitted during the pandemic), the number
on the frontlines well exceeds fifty million. Because
these workers cannot adhere to health guidelines
to socially distance, they face heightened viral risk.
A recent study of California death statistics found
that frontline workers experienced disproportionate
increases in mortality during the pandemic compared
with previous years. Workers in the food and agricul-
ture sector faced the highest excess mortality—far
greater than health care workers—suggesting that
not only exposure but also on-the-job protections
affect health risks.

Some on-the-job exposure faced by workers can be
mitigated by access to and use of personal protective
equipment (PPE). Although health care workers tend
to be prioritized for access to PPE, supply shortages
have left many of these workers vulnerable. In con-
trast, food and agriculture workers are substantially
less protected, with some employers leaving it up to
workers to provide their own PPE and some retailers
even barring use of PPE by employees to maintain a
particular image. Using a survey of more than 12,000
workers at more than 100 of the largest retail and

EXHIBIT 1

Workplace safety procedures in the service sector from March to May, 2020

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ac
ce

ss
o

r e
nf

or
ce

m
en

t o
f s

af
et

y
pr

oc
ed

ur
es

March 7 March 14 March 21 March 28 April 4 April 11 April 18 April 25 May 2 May 9 May 16 May 23

Additional cleaning

Gloves provided

Masks provided

Gloves required

Masks required

source: Ho H, Schneider D, Harknett K. COVID-19 safety measures update [Internet]. Cambridge (MA): The Shift Project; 2020 Dec [cited 2021 Apr 29]. Avail-
able from: https://shift.hks.harvard.edu/covid-19-safety-measures-update/

notes: The exhibit is reproduced with permission of the Shift Project.

3

inequalities at work and the toll of covid-19

june 2021 | health affairs

“Fifty million US workers…
are both frontline and
essential workers.”

food service firms in the US, the Shift Project tracked
workers’ reported access to PPE during the first
months of the pandemic, finding that employers
increased both the number of masks provided to
and mask requirements for workers as the pandemic
unfolded (exhibit 1). This increase coincides with an
April 2020 CDC statement advising wearing “cloth
face coverings” as a public health measure.

At the federal level, masks and other PPE are only
recommended, not required, for workers and patrons.
However, all but seven states have, at some point in
the pandemic, required masks for most frontline em-
ployees, and many cities and counties can mandate
additional PPE requirements. Nevertheless, mask
policies have been inconsistently enforced, and some
customers have resisted mask wearing, particularly
in the retail and hospitality industries. In a survey of

retail and food service workers in fall 2020, half or
more of surveyed workers from several large fast
food and casual dining restaurants and grocery stores
reported that customers do not consistently use
masks.

Workers facing COVID-19-related safety concerns on
the job have received little support from the prima-
ry agency tasked with enforcing worker health and
safety standards: the Occupational Health and Safety
Administration (OSHA). Under the Trump administra-
tion, OSHA did not issue COVID-19 safety mandates,
and enforcement activity continued a downward
trend during the pandemic. At the beginning of the
pandemic, OSHA had its lowest number of workplace
inspectors in forty-five years and there was a sig-
nificant decline in inspections, despite an increased
need. OSHA has also failed to protect workers from
retaliation in response to their registering complaints
about COVID-19-related issues.

Union representation can also improve health and
safety on the job. Unionized workplaces are 24 per-
cent more likely than nonunionized settings to have

health and safety inspections, a difference driven by
complaint-initiated inspections. In nursing homes,
where a high proportion of COVID-19 deaths have
been reported, unionization correlated with a 30 per-
cent decrease in mortality among residents. However,
just 10 percent of health care workers and 8 percent
of food or agriculture workers are union members.

Excess Risk for Low-Wage Workers,
Workers of Color, & Female Workers
Essential workers who face the greatest work-relat-
ed COVID-19 exposure risk are disproportionately
low-wage earners. Low wages are, in and of them-
selves, a risk factor for COVID-19. Workers earning
lower wages are more likely than their higher-paid
counterparts to live with large groups of people,
increasing exposure risk through increased interper-
sonal contact. Low-wage earners are also less likely
to have adequate health care and are thereby more
likely to have underlying, often untreated, conditions.
Frontline workers tend to have little financial cushion,
making it challenging to take time off work if exposed
to COVID-19 or to leave jobs with unsafe conditions.
Many are forced by financial necessity to continue
facing workplace exposure and so risk exposing their
households. When it comes to bearing risk at work,
for low-wage frontline workers, the formal distinction
between “essential” and “nonessential” is secondary
to the reality that when their workplaces are open for
business, they must work to sustain financial survival.

Workplace exposure to COVID-19 has disproportion-
ately affected workers of color because of their over-
representation in essential and frontline occupations.
People of color make up approximately 24 percent
of the US population, yet constitute approximately
40 percent of health care, grocery, convenience, and
drug store workers. A California study found excess
mortality among Latinos during the pandemic, with
food and agriculture and manufacturing employees
having some of the highest death rates. One study in
Utah found that Latino and non-White workers made
up almost three-quarters of workplace COVID-19
infections while making up just one-quarter of the
working population. Within food service, migrant
farmworkers, a largely Latino population, face
increased risk, with many experiencing overcrowded

4health policy brief

culture of health

living conditions and lacking proper sanitation, PPE,
health care, and COVID-19 testing. If they are undoc-
umented, these workers may face deportation if they
are ill and unable to work. Meat processing plants
have also become a key site of transmission and are
disproportionally staffed by workers of color, who
made up 87 percent of cases in these sites. These
differentials in workplace exposure may help contrib-
ute to differential COVID-19 mortality rates across
racial/ethnic groups.

Women also face particular work-related risk during
the pandemic. The COVID-19 recession has prompted
a disproportionate—and historically atypical—in-
crease in women’s unemployment. Women accounted
for 68.5 percent of US job losses between Febru-
ary and September 2020, despite making up 47.6
percent of employees in January and February 2020.
Women who are still working also face greater health
risks compared with working men. Occupations with
higher viral transmission also have higher proportions
of women employees, including service sector and
health care jobs. Women are especially overrepre-
sented in low-wage health work, including positions
such as home health workers and nursing assistants

and hospital staff such as janitors and cooks. These
workers tend to be given a lower priority for PPE than
clinical staff, but can face similar risks. Outside of
health care, women are overrepresented in high-viral-
risk occupations such as service sector positions and
tend to be employed in occupations with close physi-
cal proximity to coworkers and customers, increasing
risk for exposure.

Reducing COVID-19 Risk: Paid Sick
Leave And Remote Work
For workers required to report to workplaces, pro-
vision of paid sick leave is critical in containing the
spread of COVID-19, as it enables sick or exposed
workers to stay home without incurring untenable
financial loss. Although 78 percent of US workers
overall had access to some paid sick leave at the
start of the pandemic, only 30 percent of low-income
workers had access to this benefit. Workers facing
financial hardship are more likely to say that they
would still report to work if they had a fever than are
workers without such hardship. As shown in exhibit 2,
service sector workers who lack paid sick leave tend
to be financially insecure, with many struggling to pay
bills and experiencing hunger even before the pan-
demic. This creates a painful cycle for workers caught
between concern for personal and familial health and
financial survival.

The Families First Coronavirus Response Act (FF-
CRA), enacted in March 2020, provided workers with
up to two weeks of paid sick leave. A comparison of
states that gained paid sick leave through the FFCRA
and those that already had this policy suggests that
the paid sick leave expansion reduced confirmed
COVID-19 cases by 400 per day during a follow-up
period in late spring 2020. Still, many workers are not
covered by this act, as the law exempted employers
with more than 500 or fewer than 50 workers. Shift
Project data showed that 55 percent of workers at
large service sector firms had no paid sick leave just
before the pandemic.

Workers of color tend to have less paid sick leave and
stricter leave policies than White workers. Women are
less likely to have paid sick leave than are men, and
to face greater economic precarity and job insecurity
in the service sector. Women are also more likely to

EXHIBIT 2

Self-reported financial fragility among service sector
workers lacking paid sick leave

Cannot cover unexpected
$400 expense

Fell behind on bills

Exposure to hunger
hardship

Deferred medical care

Had difficulty
covering expenses

0% 10% 20% 30% 40% 50%

Workers without paid sick leave reporting difficulties

source: Schneider D, Harknett K. Essential and vulnerable: service-sector
workers and paid sick leave [Internet]. Cambridge (MA): The Shift Project; 2020
Apr [cited 2021 Apr 29]. Available from: https://shift.hks.harvard.edu/essential-
and-vulnerable-service-sector-workers-and-paid-sick-leave/

notes: Survey data collected September 2017–November 2019. The exhibit
is reproduced with permission of the Shift Project.

5

inequalities at work and the toll of covid-19

june 2021 | health affairs

“Workplace exposure
to COVID-19 has
disproportionately affected
workers of color.”

report all measures of economic fragility than the
overall service sector population. These trends put
already-vulnerable populations at greater risk for
financial hardship during the pandemic and make them
more likely to spread COVID-19 should they contract
it, as—out of necessity—they may go to work while ill.

Roughly half of US workers are now working remotely
and thus have greatly reduced risk for COVID-19
exposure, but this group is not representative of US

workers overall. White-collar workers, as well as older,
highly educated, and higher-income employees, are
more likely to have the option to work from home and
to do so successfully, given the home environment
and household responsibilities afforded them. Facing
regular viral exposure, frontline, nonremote work-
ers are more likely than the overall workforce to be
women and people of color and to have lower levels of
educational attainment and lower incomes.

The Work-Family Crisis Faced By
Parents
For working parents, both frontline and remote,
COVID-19 has exacerbated conflicts between work
and caretaking responsibilities. The closure of
schools and childcare centers has made pandemic
life difficult for those with young children, who often
struggle to find childcare and manage fully or partial-
ly remote schooling. The informal support networks
many parents rely on have become less feasible,
given the increase in viral risk resulting from close
contact with others. This is especially true because
many informal caregivers are older adults, such as
grandparents, who are at high risk for COVID-19.

Caregivers also experience significant emotional
distress navigating work and care, as COVID-19 has

limited access to support networks. According to
a national survey, 27 percent of parents said their
mental health had deteriorated as a result of the pan-
demic. A daily survey of hourly service workers with
young children found declines in parents’ psychologi-
cal well-being during the pandemic. In this same study,
45 percent of respondents reported an increased
childcare burden, which was significantly related to
children’s “uncooperative behavior and worry.”

The toll of the pandemic for working parents has fall-
en heavily on women. A survey in the early months of
the pandemic found that women were almost twice as
likely as men to report bearing primary responsibility
for overseeing children’s remote schooling and gen-
eral care. Data from the Current Population Survey
early in the pandemic indicate that working mothers
with young children cut back their work hours to
provide care four to five times as much compared
with working fathers. Although time use data suggest
that the pandemic may have narrowed the gender gap
in child care among parents working from home, the
gender gap in housework widened. Further, survey
data show that mothers working from home report
worse mental health compared with fathers.

A Policy Agenda To Protect And
Empower Workers
Fast and efficient distribution of COVID-19 vaccines
to frontline workers is of paramount importance in
keeping US workers and the public safe in the near
term. However, other immediate policy action is
needed. Our policy recommendations are designed to
protect workers during the pandemic and to lay the
groundwork for worker empowerment and opportuni-
ty in the future.

EMPOWER WORKERS TO AVOID UNSAFE CONDITIONS
All workers should be entitled to paid sick leave so
that they do not need to choose between missing a
paycheck or going to work sick. Access to paid sick
leave enables workers to quarantine safely without
risking their financial well-being, protecting both the
workers and the public. Current paid sick leave laws
are a patchwork of local legislation and voluntary
company action. A national paid sick leave guarantee

culture of health

This Health Policy Brief was produced with the generous support of the Robert Wood Johnson Foundation. All briefs go through peer review before
publication.

Written by Rebecca Wolfe, a doctoral candidate in the Department of Social and Behavioral Sciences at the University of California San Francisco; Kristen
Harknett, associate professor in the Department of Social and Behavioral Sciences at the University of California San Francisco; and Daniel Schneider,
professor of public policy at the Harvard Kennedy School, Harvard University, in Cambridge, Massachusetts. Harknett and Schneider are principal
investigators of the Shift Project at Harvard University.

Cite as: “Inequalities At Work And The Toll Of COVID-19,” Health Affairs Health Policy Brief, June 4, 2021. DOI: 10.1377/hpb20210428.863621
7500 Old Georgetown Road, Suite 600 | Bethesda, Maryland 20814-6133 USA | © 2021 Project HOPE—The People-to-People Health Foundation, Inc.

that imposes a minimum standard would ensure equi-
table access to this benefit.

Further, workers should be entitled to unemployment
benefits if they cannot continue working because
they are unsafe at work. A recent executive order
from President Biden has opened the door to expand-
ed access to unemployment insurance benefits for
those who leave a job because they feel unsafe at
work during the pandemic, although it remains to be
seen how accessible these benefits will be for such
workers.

Worker and public health would also be protected by
a higher minimum wage, as workers could take unpaid
time off without risking a financial crisis. A higher
minimum wage may also confer additional health
benefits. Policy makers should also consider extend-
ing hazard pay compensation to frontline workers for
the elevated health risks they endure by showing up
to work during a pandemic.

ENFORCE SAFETY STANDARDS AT WORK
OSHA must be fully staffed and strengthened to pro-
tect workers during the pandemic. The Biden adminis-
tration has taken a step in this direction. An executive
order signed in January 2021 ordered OSHA to issue
revised workplace safety guidance for the pandemic
and to focus enforcement on major COVID-19 viola-
tions. Shortly thereafter, OSHA issued stronger guid-
ance on COVID-19 workplace safety, recommending
that employers implement COVID-19 prevention
programs including hazard assessments, nonpunitive
employee absence policies to encourage infected
workers to stay home, and whistleblower protection
for employees reporting COVID-19-related safety

concerns. An important next step is for OSHA to issue
an Emergency Temporary Standard, which would
make these recommendations legally enforceable.
OSHA could also publicize sanctions against violating
firms, which research shows is a highly effective tool
for increasing compliance.

PRIORITIZE SAFE REOPENING OF SCHOOLS AND
CHILDCARE CENTERS
Safe reopening of schools and childcare centers will
lessen the strain on working parents. Despite the
essential importance of schools in the national infra-
structure, businesses such as bars and restaurants
have opened before these institutions. Reopening
schools and childcare centers would be particular-
ly impactful for working mothers who are bearing
the brunt of the added pandemic-related childcare
responsibilities and experiencing the most severe
economic and mental health consequences.

Conclusion
With the introduction of vaccines and the hope for
herd immunity on the horizon, the threat of COVID-19
may subside in the latter half of 2021. Nevertheless,
inequality in workplace exposure to health risks
and economic insecurity will endure. The COVID-19
pandemic has revealed stark inequalities in exposure
to workplace risk and access to protective policies.
The shock has created a new urgency and impera-
tive to make risk-reduction and protective policies
universally and equitably available to workers across
the occupational, demographic, and socioeconomic
spectrum.

culture of health

with support from:

www.healthaffairs.org/briefs

health policy brief  june 2021

Work plays a key role in moderating the COVID-19 pandemic experiences
of Americans and in imposing economic and social costs on households.

Frontline workers, many of whom are considered “essential,” face dispropor-
tionate health risks as they weather the pandemic. At the same time, many
white-collar workers have transitioned to remote work, often while simul-
taneously caring for dependent children, leading to severe role strain and
work-life conflicts.

The often-dire consequences of the pandemic are stratified along race, gender,
class, and occupational lines. In this brief we explore how existing inequalities
at work across these same categories perpetuate inequalities in the toll of
COVID-19. Before the pandemic, many of those currently working in frontline
positions faced low wages, few benefits, and erratic schedules. (Note: All linked
references in this brief are also listed in supplemental exhibit 1.)

Many of these issues have only intensified during the COVID-19 pandemic.
We highlight the importance of—and inequalities in—on-the-job conditions
that affect viral exposure risk and fringe benefits such as paid sick leave and
the ability to work from home that allow workers to manage risk. We also
propose policy recommendations to lessen these inequalities during the
pandemic and for the service sector moving forward. We do not recommend
a return to prepandemic standards but, instead, a movement toward a better
and more equitable future for employees.

The COVID-19 pandemic has laid bare existing
inequalities in workplace exposure to
health risks and economic insecurity. Policy
action is needed to protect workers’ health
during the pandemic and to support worker
empowerment and equitable opportunities in
the future.

INEQUALITIES AT WORK AND THE
TOLL OF COVID-19

Key Points
» Workplaces shape risk for exposure to

COVID-19 through on-site safety practices,
including the provision and required use of
personal protective equipment, as well as
protective policies such as paid sick leave and
the flexibility to work from home.

» More than one in every five US workers has
no paid sick leave. Recent expansions of paid
sick leave coverage still exclude many workers.
Low-wage workers are far more likely than their
higher-paid counterparts to lack paid sick leave
but are the least able to afford to take unpaid
time off from work when ill.

» Women, people of color, and those of lower
socioeconomic status are the most likely
among all workers to hold frontline positions
that require in-person work and the least
likely to have paid sick leave. These groups
have disproportionately experienced the
negative health and economic consequences of
COVID-19.

» Women have been disproportionately affected
by job loss and the caregiving burdens arising
from school and care provider closures, with
consequences for their career opportunities,
economic security, and mental health.

» Governmental action is needed on several
fronts: to empower workers by raising wages
and providing universal paid sick leave, to
strengthen COVID-19 workplace safety
mandates and enforcement of workplace safety
standards via the Occupational Health and
Safety Administration, and to prioritize a safe
reopening of schools and childcare centers.

2health policy brief

culture of health

On-The-Job Exposure To COVID-19
Risk
A key Centers for Disease Control and Prevention
(CDC) recommendation for containing the COVID-19
pandemic is minimizing exposure to persons outside
of one’s household. The CDC advises avoidance of
indoor interactions because infection risk increases
in enclosed spaces, particularly during extended
periods. Many essential workplaces are thus high-risk
environments, bringing coworkers and consumers to-
gether indoors, with most work shifts lasting multiple
hours.

Fifty million US workers (34.5 percent of all workers)
are both frontline and essential workers, meaning
that they cannot work from home and their work is
essential to meeting basic population needs. In this
case, essential workers are those employed at a busi-
ness or establishment that “must stay open during a
public health emergency.” When nonessential workers
are included (for example, those in restaurants and
retail establishments that have chosen to remain

open as permitted during the pandemic), the number
on the frontlines well exceeds fifty million. Because
these workers cannot adhere to health guidelines
to socially distance, they face heightened viral risk.
A recent study of California death statistics found
that frontline workers experienced disproportionate
increases in mortality during the pandemic compared
with previous years. Workers in the food and agricul-
ture sector faced the highest excess mortality—far
greater than health care workers—suggesting that
not only exposure but also on-the-job protections
affect health risks.

Some on-the-job exposure faced by workers can be
mitigated by access to and use of personal protective
equipment (PPE). Although health care workers tend
to be prioritized for access to PPE, supply shortages
have left many of these workers vulnerable. In con-
trast, food and agriculture workers are substantially
less protected, with some employers leaving it up to
workers to provide their own PPE and some retailers
even barring use of PPE by employees to maintain a
particular image. Using a survey of more than 12,000
workers at more than 100 of the largest retail and

EXHIBIT 1

Workplace safety procedures in the service sector from March to May, 2020

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ac
ce

ss
o

r e
nf

or
ce

m
en

t o
f s

af
et

y
pr

oc
ed

ur
es

March 7 March 14 March 21 March 28 April 4 April 11 April 18 April 25 May 2 May 9 May 16 May 23

Additional cleaning

Gloves provided

Masks provided

Gloves required

Masks required

source: Ho H, Schneider D, Harknett K. COVID-19 safety measures update [Internet]. Cambridge (MA): The Shift Project; 2020 Dec [cited 2021 Apr 29]. Avail-
able from: https://shift.hks.harvard.edu/covid-19-safety-measures-update/

notes: The exhibit is reproduced with permission of the Shift Project.

3

inequalities at work and the toll of covid-19

june 2021 | health affairs

“Fifty million US workers…
are both frontline and
essential workers.”

food service firms in the US, the Shift Project tracked
workers’ reported access to PPE during the first
months of the pandemic, finding that employers
increased both the number of masks provided to
and mask requirements for workers as the pandemic
unfolded (exhibit 1). This increase coincides with an
April 2020 CDC statement advising wearing “cloth
face coverings” as a public health measure.

At the federal level, masks and other PPE are only
recommended, not required, for workers and patrons.
However, all but seven states have, at some point in
the pandemic, required masks for most frontline em-
ployees, and many cities and counties can mandate
additional PPE requirements. Nevertheless, mask
policies have been inconsistently enforced, and some
customers have resisted mask wearing, particularly
in the retail and hospitality industries. In a survey of

retail and food service workers in fall 2020, half or
more of surveyed workers from several large fast
food and casual dining restaurants and grocery stores
reported that customers do not consistently use
masks.

Workers facing COVID-19-related safety concerns on
the job have received little support from the prima-
ry agency tasked with enforcing worker health and
safety standards: the Occupational Health and Safety
Administration (OSHA). Under the Trump administra-
tion, OSHA did not issue COVID-19 safety mandates,
and enforcement activity continued a downward
trend during the pandemic. At the beginning of the
pandemic, OSHA had its lowest number of workplace
inspectors in forty-five years and there was a sig-
nificant decline in inspections, despite an increased
need. OSHA has also failed to protect workers from
retaliation in response to their registering complaints
about COVID-19-related issues.

Union representation can also improve health and
safety on the job. Unionized workplaces are 24 per-
cent more likely than nonunionized settings to have

health and safety inspections, a difference driven by
complaint-initiated inspections. In nursing homes,
where a high proportion of COVID-19 deaths have
been reported, unionization correlated with a 30 per-
cent decrease in mortality among residents. However,
just 10 percent of health care workers and 8 percent
of food or agriculture workers are union members.

Excess Risk for Low-Wage Workers,
Workers of Color, & Female Workers
Essential workers who face the greatest work-relat-
ed COVID-19 exposure risk are disproportionately
low-wage earners. Low wages are, in and of them-
selves, a risk factor for COVID-19. Workers earning
lower wages are more likely than their higher-paid
counterparts to live with large groups of people,
increasing exposure risk through increased interper-
sonal contact. Low-wage earners are also less likely
to have adequate health care and are thereby more
likely to have underlying, often untreated, conditions.
Frontline workers tend to have little financial cushion,
making it challenging to take time off work if exposed
to COVID-19 or to leave jobs with unsafe conditions.
Many are forced by financial necessity to continue
facing workplace exposure and so risk exposing their
households. When it comes to bearing risk at work,
for low-wage frontline workers, the formal distinction
between “essential” and “nonessential” is secondary
to the reality that when their workplaces are open for
business, they must work to sustain financial survival.

Workplace exposure to COVID-19 has disproportion-
ately affected workers of color because of their over-
representation in essential and frontline occupations.
People of color make up approximately 24 percent
of the US population, yet constitute approximately
40 percent of health care, grocery, convenience, and
drug store workers. A California study found excess
mortality among Latinos during the pandemic, with
food and agriculture and manufacturing employees
having some of the highest death rates. One study in
Utah found that Latino and non-White workers made
up almost three-quarters of workplace COVID-19
infections while making up just one-quarter of the
working population. Within food service, migrant
farmworkers, a largely Latino population, face
increased risk, with many experiencing overcrowded

4health policy brief

culture of health

living conditions and lacking proper sanitation, PPE,
health care, and COVID-19 testing. If they are undoc-
umented, these workers may face deportation if they
are ill and unable to work. Meat processing plants
have also become a key site of transmission and are
disproportionally staffed by workers of color, who
made up 87 percent of cases in these sites. These
differentials in workplace exposure may help contrib-
ute to differential COVID-19 mortality rates across
racial/ethnic groups.

Women also face particular work-related risk during
the pandemic. The COVID-19 recession has prompted
a disproportionate—and historically atypical—in-
crease in women’s unemployment. Women accounted
for 68.5 percent of US job losses between Febru-
ary and September 2020, despite making up 47.6
percent of employees in January and February 2020.
Women who are still working also face greater health
risks compared with working men. Occupations with
higher viral transmission also have higher proportions
of women employees, including service sector and
health care jobs. Women are especially overrepre-
sented in low-wage health work, including positions
such as home health workers and nursing assistants

and hospital staff such as janitors and cooks. These
workers tend to be given a lower priority for PPE than
clinical staff, but can face similar risks. Outside of
health care, women are overrepresented in high-viral-
risk occupations such as service sector positions and
tend to be employed in occupations with close physi-
cal proximity to coworkers and customers, increasing
risk for exposure.

Reducing COVID-19 Risk: Paid Sick
Leave And Remote Work
For workers required to report to workplaces, pro-
vision of paid sick leave is critical in containing the
spread of COVID-19, as it enables sick or exposed
workers to stay home without incurring untenable
financial loss. Although 78 percent of US workers
overall had access to some paid sick leave at the
start of the pandemic, only 30 percent of low-income
workers had access to this benefit. Workers facing
financial hardship are more likely to say that they
would still report to work if they had a fever than are
workers without such hardship. As shown in exhibit 2,
service sector workers who lack paid sick leave tend
to be financially insecure, with many struggling to pay
bills and experiencing hunger even before the pan-
demic. This creates a painful cycle for workers caught
between concern for personal and familial health and
financial survival.

The Families First Coronavirus Response Act (FF-
CRA), enacted in March 2020, provided workers with
up to two weeks of paid sick leave. A comparison of
states that gained paid sick leave through the FFCRA
and those that already had this policy suggests that
the paid sick leave expansion reduced confirmed
COVID-19 cases by 400 per day during a follow-up
period in late spring 2020. Still, many workers are not
covered by this act, as the law exempted employers
with more than 500 or fewer than 50 workers. Shift
Project data showed that 55 percent of workers at
large service sector firms had no paid sick leave just
before the pandemic.

Workers of color tend to have less paid sick leave and
stricter leave policies than White workers. Women are
less likely to have paid sick leave than are men, and
to face greater economic precarity and job insecurity
in the service sector. Women are also more likely to

EXHIBIT 2

Self-reported financial fragility among service sector
workers lacking paid sick leave

Cannot cover unexpected
$400 expense

Fell behind on bills

Exposure to hunger
hardship

Deferred medical care

Had difficulty
covering expenses

0% 10% 20% 30% 40% 50%

Workers without paid sick leave reporting difficulties

source: Schneider D, Harknett K. Essential and vulnerable: service-sector
workers and paid sick leave [Internet]. Cambridge (MA): The Shift Project; 2020
Apr [cited 2021 Apr 29]. Available from: https://shift.hks.harvard.edu/essential-
and-vulnerable-service-sector-workers-and-paid-sick-leave/

notes: Survey data collected September 2017–November 2019. The exhibit
is reproduced with permission of the Shift Project.

5

inequalities at work and the toll of covid-19

june 2021 | health affairs

“Workplace exposure
to COVID-19 has
disproportionately affected
workers of color.”

report all measures of economic fragility than the
overall service sector population. These trends put
already-vulnerable populations at greater risk for
financial hardship during the pandemic and make them
more likely to spread COVID-19 should they contract
it, as—out of necessity—they may go to work while ill.

Roughly half of US workers are now working remotely
and thus have greatly reduced risk for COVID-19
exposure, but this group is not representative of US

workers overall. White-collar workers, as well as older,
highly educated, and higher-income employees, are
more likely to have the option to work from home and
to do so successfully, given the home environment
and household responsibilities afforded them. Facing
regular viral exposure, frontline, nonremote work-
ers are more likely than the overall workforce to be
women and people of color and to have lower levels of
educational attainment and lower incomes.

The Work-Family Crisis Faced By
Parents
For working parents, both frontline and remote,
COVID-19 has exacerbated conflicts between work
and caretaking responsibilities. The closure of
schools and childcare centers has made pandemic
life difficult for those with young children, who often
struggle to find childcare and manage fully or partial-
ly remote schooling. The informal support networks
many parents rely on have become less feasible,
given the increase in viral risk resulting from close
contact with others. This is especially true because
many informal caregivers are older adults, such as
grandparents, who are at high risk for COVID-19.

Caregivers also experience significant emotional
distress navigating work and care, as COVID-19 has

limited access to support networks. According to
a national survey, 27 percent of parents said their
mental health had deteriorated as a result of the pan-
demic. A daily survey of hourly service workers with
young children found declines in parents’ psychologi-
cal well-being during the pandemic. In this same study,
45 percent of respondents reported an increased
childcare burden, which was significantly related to
children’s “uncooperative behavior and worry.”

The toll of the pandemic for working parents has fall-
en heavily on women. A survey in the early months of
the pandemic found that women were almost twice as
likely as men to report bearing primary responsibility
for overseeing children’s remote schooling and gen-
eral care. Data from the Current Population Survey
early in the pandemic indicate that working mothers
with young children cut back their work hours to
provide care four to five times as much compared
with working fathers. Although time use data suggest
that the pandemic may have narrowed the gender gap
in child care among parents working from home, the
gender gap in housework widened. Further, survey
data show that mothers working from home report
worse mental health compared with fathers.

A Policy Agenda To Protect And
Empower Workers
Fast and efficient distribution of COVID-19 vaccines
to frontline workers is of paramount importance in
keeping US workers and the public safe in the near
term. However, other immediate policy action is
needed. Our policy recommendations are designed to
protect workers during the pandemic and to lay the
groundwork for worker empowerment and opportuni-
ty in the future.

EMPOWER WORKERS TO AVOID UNSAFE CONDITIONS
All workers should be entitled to paid sick leave so
that they do not need to choose between missing a
paycheck or going to work sick. Access to paid sick
leave enables workers to quarantine safely without
risking their financial well-being, protecting both the
workers and the public. Current paid sick leave laws
are a patchwork of local legislation and voluntary
company action. A national paid sick leave guarantee

culture of health

This Health Policy Brief was produced with the generous support of the Robert Wood Johnson Foundation. All briefs go through peer review before
publication.

Written by Rebecca Wolfe, a doctoral candidate in the Department of Social and Behavioral Sciences at the University of California San Francisco; Kristen
Harknett, associate professor in the Department of Social and Behavioral Sciences at the University of California San Francisco; and Daniel Schneider,
professor of public policy at the Harvard Kennedy School, Harvard University, in Cambridge, Massachusetts. Harknett and Schneider are principal
investigators of the Shift Project at Harvard University.

Cite as: “Inequalities At Work And The Toll Of COVID-19,” Health Affairs Health Policy Brief, June 4, 2021. DOI: 10.1377/hpb20210428.863621
7500 Old Georgetown Road, Suite 600 | Bethesda, Maryland 20814-6133 USA | © 2021 Project HOPE—The People-to-People Health Foundation, Inc.

that imposes a minimum standard would ensure equi-
table access to this benefit.

Further, workers should be entitled to unemployment
benefits if they cannot continue working because
they are unsafe at work. A recent executive order
from President Biden has opened the door to expand-
ed access to unemployment insurance benefits for
those who leave a job because they feel unsafe at
work during the pandemic, although it remains to be
seen how accessible these benefits will be for such
workers.

Worker and public health would also be protected by
a higher minimum wage, as workers could take unpaid
time off without risking a financial crisis. A higher
minimum wage may also confer additional health
benefits. Policy makers should also consider extend-
ing hazard pay compensation to frontline workers for
the elevated health risks they endure by showing up
to work during a pandemic.

ENFORCE SAFETY STANDARDS AT WORK
OSHA must be fully staffed and strengthened to pro-
tect workers during the pandemic. The Biden adminis-
tration has taken a step in this direction. An executive
order signed in January 2021 ordered OSHA to issue
revised workplace safety guidance for the pandemic
and to focus enforcement on major COVID-19 viola-
tions. Shortly thereafter, OSHA issued stronger guid-
ance on COVID-19 workplace safety, recommending
that employers implement COVID-19 prevention
programs including hazard assessments, nonpunitive
employee absence policies to encourage infected
workers to stay home, and whistleblower protection
for employees reporting COVID-19-related safety

concerns. An important next step is for OSHA to issue
an Emergency Temporary Standard, which would
make these recommendations legally enforceable.
OSHA could also publicize sanctions against violating
firms, which research shows is a highly effective tool
for increasing compliance.

PRIORITIZE SAFE REOPENING OF SCHOOLS AND
CHILDCARE CENTERS
Safe reopening of schools and childcare centers will
lessen the strain on working parents. Despite the
essential importance of schools in the national infra-
structure, businesses such as bars and restaurants
have opened before these institutions. Reopening
schools and childcare centers would be particular-
ly impactful for working mothers who are bearing
the brunt of the added pandemic-related childcare
responsibilities and experiencing the most severe
economic and mental health consequences.

Conclusion
With the introduction of vaccines and the hope for
herd immunity on the horizon, the threat of COVID-19
may subside in the latter half of 2021. Nevertheless,
inequality in workplace exposure to health risks
and economic insecurity will endure. The COVID-19
pandemic has revealed stark inequalities in exposure
to workplace risk and access to protective policies.
The shock has created a new urgency and impera-
tive to make risk-reduction and protective policies
universally and equitably available to workers across
the occupational, demographic, and socioeconomic
spectrum.