Work Matters: Mainstreaming Worker Health and Safety Is Not Limited to Pandemic Response

During the depths of the COVID-19 pandemic, with stay-at-home orders, quiet urban streets punctuated by ambulance sirens, the frequent sound of helicopters transferring critically ill patients, widespread fear and anxiety, hospital understaffing, and protective equipment shortages, the continued work and enormous commitment of essential public-facing workers highlighted the importance of work as a determinant of the health status of workers, their families, communities, and the country. People who worked outside their homes—in hospitals, chronic care facilities, public safety, transportation, commercial delivery, and food production and sale—were celebrated as “heroes.” Daily press stories made it clear: work matters for worker and community health and well-being.

But the spotlight shifted as vaccines became widely available, fear abated, the risk of infection from going to and being at work was less pronounced, and many workers began suffering from burnout and other mental health challenges. Workers willing to take care of the sick and elderly, people delivering packages that we were no longer sanitizing, and teachers who were trying to protect their own health in poorly ventilated classrooms, were no longer national heroes, and their ongoing importance faded from the media.

The experience of the recent pandemic underscores the need, advocated by Alfredo Morabia, the editor-in-chief of AJPH, to maintain a focus on the centrality of work or its absence in the lives of virtually everyone by bringing worker health and safety into the mainstream of public health.¹

The importance of “mainstreaming” worker health and safety is not limited to pandemic response. Work policies, practices, and exposures influence the health of workers and their families outside of work in obvious and subtle ways. Work is central to the lives of people who work, providing financial and social support and purpose; thus, work is a major driver of overall well-being. Poor and hazardous working conditions can cause or contribute to injury, disease, premature death, burnout, and addiction.² For many, work is a source of health insurance, an important factor in access to some degree of sickness care for many workers and their families. And the absence of work drives poverty, inequality, and despair. The consequences of the quality of work are felt by workers, their families, and the communities in which they live.

Nevertheless, although the World Health Organization has for decades noted that health is more than the absence of disease and has recognized that employment and working conditions have powerful effects on health and health equity,³ work and the potential to improve working conditions are too often overlooked as an opportunity for public health engagement.

OLD HAZARDS WITH GROWING CONSEQUENCES

There have been many missed opportunities for collaborative approaches, combining general public health and occupational health expertise and authorities, that aim to prevent or mitigate disease. A few recent examples of the inadequacy of the public health system’s response to well-known work hazards that are emerging in new and dangerous forms illustrate many of the weaknesses of these systems.

Airborne Pathogens

In the face of the pandemic, it is difficult to recall that coronaviruses have long been recognized as one of the pathogens causing mild to moderate respiratory illness, often called the “common cold.” Workers are regularly infected by airborne pathogens that include coronavirus and influenza, pass infections on to fellow workers, and bring infections home. In addition to those employed in health care settings, teachers, retail workers, and others in public-facing jobs have higher risk of respiratory infections.⁴ For many jobs, particularly office-based work, respiratory infections are a major cause of work absence.⁵ Unlike in other high-income countries, paid sick leave that would enable workers to stay home when they might infect others is far from universal in the United States.

The novel SARS-CoV-2 virus (the causative agent of COVID-19) is a ramped-up version of the pathogen causing colds. Workplace transmission of airborne pathogens like coronavirus has been tolerated without regulation or interventions for years. Early evidence and common sense identified the risk of infection transmission in nursing homes, hospitals, and meat-processing plants, but the risk to other workers was generally ignored, delaying public health efforts to protect workers with heightened risk.

As a rule, the responsibility and authority for public health action resides in local, county, and state health departments. Public health authorities, strapped for resources, do not have the expertise, and do not consider it within their domain to enter workplaces and use their powers to reduce risk to workers. That is seen as the responsibility of a federal agency, the Occupational Safety and Health Administration (OSHA). But OSHA did not have adequate tools in place to require employers to take steps necessary to protect their employees from SARS-CoV-2, even those in health care facilities.⁶

Climate Change–Related Hazards

The climate crisis is increasing the risk to workers from exposure to wildfire smoke, extreme heat, vector-borne illnesses, and other hazards.⁷

Wildfires are increasing, creating smoke that travels great distances, elevating toxic exposures associated with respiratory and cardiovascular disease. Everyone in New York City and Washington, DC, including outdoor workers, experienced the highly polluted air from Canadian wildfires for days in 2023.

A recent National Academies report found that the nation is unprepared to provide respiratory protection for most workers exposed to airborne viruses or wildfire smoke.⁸ The response to the report was almost complete silence from Congress or the federal agencies whose job it is to protect the public’s health.

Extreme heat exposure, in both outdoor and indoor workplaces, is also becoming more common and more deadly. Heat not only kills directly but also increases the risk of renal failure, cardiovascular disease, ischemic stroke, and workplace injuries.^9,10 Federal OSHA’s standard setting process is extremely slow and resource intensive. Although a few state OSHA plans have standards requiring rest breaks, shade, and rehydration, regulations that cover much of the country are unlikely to be issued in the next several years.

Respirable Crystalline Silica

Silica dust is another well-known deadly resurging hazard. Although both federal and California OSHA plans have standards requiring employers to limit exposure, the fabrication of countertops made from “engineered” stone has resulted in dozens of California workers developing silicosis. In severe cases, some workers have died, and others have needed lung transplants.¹¹

COORDINATION FAILURES HAVE CONSEQUENCES

In addressing each of these hazards, collaboration and communication between the occupational safety and health (OSH) regulatory system and the mainstream public health system have been inadequate or absent. Although for decades work has been acknowledged as a “social determinant of health” nationally and internationally,^2,3 the separation of OSH from mainstream public health has, if anything, grown.

Before the passage of the Occupational Safety and Health Act in 1970, many state and local governments had workplace inspection units. Some of those state offices transitioned to become state OSHA plans, but others atrophied or disappeared. During the COVID-19 pandemic, few state and local government agencies other than a limited number of state OSHA programs routinely responded to workplace outbreaks in which many workers were sickened.

OSH is too often viewed as a field apart, with distinct knowledge, attitudes, and beliefs. It is pigeonholed as “industrial health,” concerned with conditions of the past that will gradually fade away in the United States through a combination of regulation and deindustrialization. It may be misunderstood as focused exclusively on injuries from work and their compensation.

Research investigations published in this and other scientific journals repeatedly confirmed the association of COVID-19 risk with workplace exposures, and that work outside the home contributed to disparities in illness and death.^12,13 Early in the pandemic, workplaces—including nursing homes, hospitals, meatpacking facilities, prisons, and retail establishments—played an important role in spreading the virus throughout much of the country, especially rural areas.^14–16 Yet there was little coordination between the state and local public health agencies that played a lead role in the nation’s pandemic response and the federal and state OSHA programs with authority over workplaces.

In addition, much of the public health messaging from the Centers for Disease Control and Prevention stressed the importance of actions individuals could take, emphasizing handwashing, maintaining six feet of social distance, and mask wearing.

In contrast, occupational health experts recommended the application of the fundamental principles of worker protection: the hierarchy of controls.¹⁷ These experts recognized that to control the workplace spread of SARS-CoV-2, it would be more effective to make the environment safer for all rather than by exclusively relying on individuals to change their behaviors.

Applying the hierarchy to COVID-19 risk reduction, the first steps are to eliminate the exposure through keeping sick and potentially infectious workers out of the workplace and by utilizing engineering controls that provide virus-free air. Although useful in conjunction with other controls, personal protective equipment like respirators is not as effective as environmental interventions. We believe that wider implementation of the hierarchy of controls would have helped slow the workplace spread of the virus, saving many lives.

The chasm between OSH and mainstream public health is mirrored in mainstream medicine, where medical treatment of illness and injuries from work is often separated from the rest of the health care system. Workers’ compensation insurance systems vary by state, with differences in standards of diagnosis and proof for compensation of injuries and diseases from work. Many people with injuries or illnesses caused or made worse by workplace exposures elect to avoid entering the workers’ compensation system, shifting the costs of work-related conditions from the employer (where, by law, they belong) to the worker and their families, their coworkers, and taxpayers. Other barriers to obtaining compensation, including shrinking pools of key medical personnel able and willing to diagnose conditions as occupational when reaching that conclusion, result in both time-consuming engagement with an often-unfamiliar administrative process and substandard levels of payment for providing treatment.^18,19

CLOSING THE GAP

Public health policy and funding priorities are often set by measuring or enumerating conditions of concern. When only compensated injuries and diseases are counted as work-related, there is substantial undercounting of the extent of problems and, consequently, the importance of working conditions to health, safety, and well-being.^20,21

Efforts to integrate OSH with mainstream public health and health care run into strong headwinds. Data tying health and illness to work are limited and often lack the granularity to be useful.^22,23 Both health and exposure surveillance are critical to the recognition of problems, the design and evaluation of interventions, and the recognition of disparities. The adoption of electronic medical records offered hope that individuals’ work could be tied to health outcomes and that information about their industries and occupations could result in a better understanding of their work exposures. But even if information about work and work exposures is included in the electronic medical record, most clinicians are inadequately trained and are generally too stressed by their own workplace demands to link diagnosis and treatment to the work of their working patients.

The failure to integrate OSH and mainstream public health has resulted in disparate levels of protection. There is limited recognition that workers are often exposed “first and worst” to toxic chemicals, and that the same exposures can escape the workplace perimeter and adversely affect local communities and beyond. This is a particular environmental justice concern for communities with little political power, including low-income ones, where workplaces with significant chemical hazards are often situated.²⁴

Although, overall, workers generally start out healthier than many nonworking community members, the levels of protection afforded them at work through governmental regulation and enforcement are limited and reflect an implicit social belief that workers are getting paid for their health risk at work and if they don’t like it, they can leave. But too many leave work because of adverse health effects from work.

People who work full-time spend almost a third of their waking lives at or getting to or from work. Work and work-related activities are a potential source of both adverse and beneficial exposures that may determine worker health, safety, and well-being as well as the health of their communities. However, research into the contributions of work to chronic disease risk is limited. Most occupational diseases are indistinguishable from diseases of “everyday life” such as chronic obstructive pulmonary disease, cardiovascular disease, cancer, and asthma. To understand the risk conferred by workplace toxic exposures and stressors, investigators need to take into consideration work exposures, including the policies governing work. Too often, when chronic disease prevention scientists and practitioners turn their attention to the workplace, their focus is on motivating modification of individual choices and habits, using the workplace as a convenient venue to access individuals for health promotion interventions. A more useful approach was taken by Berkman et al., who demonstrated that an intervention designed specifically to increase employees’ control over work time and supervisors’ awareness and support of work–family balance resulted in improved worker health.²⁵

Given the central role work plays in determining the health of workers, their families, and communities, the separation of worker protection and mainstream public health has worked to the detriment of everyone. To actually address work as a social determinant of health, now is the time to begin reintegrating these fields.

Public health is a sprawling, diverse, and multilayered system intended to protect the health, safety, and well-being of all people and their communities. Public health success is so “normal” that, absent emergencies, funding support for public health agencies dwindles. Agencies with different roles in protecting public health and well-being are often given limited power and inadequate funding, compete with one another for limited resources, and fail to collaborate or even communicate with one another. This results, unfortunately, in the “suboptimization” of overall public protection. The examples presented earlier as well as our decades of experience in public health, occupational health and safety, and sickness care, in roles including practice, research, teaching, advocacy, and organizational leadership in and out of the government, have led us to believe that these complex problems will benefit from the mainstream public health and OSH communities working closely and continually together for improved prevention and protection for all. This can be achieved when those involved with “traditional public health” and those engaged in OSH commit to understanding, embracing, and acting on the concept that work is a key determinant of personal, family, and community health and that the conditions of work, and both the public and enterprise-specific policies that influence them, are broadly important. In this way, not only will future pandemic response be more effective and outbreaks of work-related disease, injury, and death be better investigated, mitigated, and prevented, but quotidian public health problems and opportunities will be addressed more effectively as well.