The Gig Economy Worker: A New Social Determinant of Health?

“A man’s employment status was a stronger predictor of his risk of dying from coronary heart disease than any of the more familiar risk factors.”

This was the authors’ poignant conclusion of the landmark Whitehall epidemiological study.¹ British civil servants with the lowest grade occupation, compared to those in the highest grade, had three times the risk of cardiovascular death. Similar findings across diverse settings have linked occupation-based physical inactivity to a higher prevalence of cardiovascular disease (CVD) risk factors and poor outcomes.^2,3

As we fast forward to present times, employment and health remain inextricably linked. In particular, the rapid rise of the gig economy has resulted in a fast-growing workforce segment with unique health vulnerabilities. The cardinal feature of the gig economy is that workers are independent contractors or freelancers who perform short-term, contingent work. Gig employers serve as intermediaries, or “digital matching firms” that match workers to customers, often using digital platforms.⁴ Modern gig work gained traction with the rise of the internet in the early 2000s with companies such as Amazon and Uber.

The rapid rise of gig work has been striking. In 2019, there were 57 million freelance workers, contributing to 5% of the U.S. Gross Domestic Product.⁵ During the COVID-19 pandemic, the demand for gig services such as home delivery skyrocketed, and people who lost full-time employment switched to gig work. The gig structure may be appealing to freelancers, customers, and digital platform companies. Benefits include work-hour flexibility, greater market efficiency, lower costs of services, and titratability of supply to match demand.

Yet, the very nature of the gig economy may lead to systemic increases in cardiovascular risk that stem from its structural underpinnings. Freelance driving represents the flagship sector of the gig economy, whether for passenger rideshare, local delivery, or long-haul trucking. There are over 3.9 million Uber drivers worldwide, with an increasing number of racial/ethnic minorities, women, and veterans. Drivers of limited English proficiency or those who are foreign-born may disproportionately take part in driving.⁶

Gig driving, like taxi or bus driving, can increase cardiovascular risks. Landmark work in the 1950’s showed that coronary heart disease deaths were approximately twice as frequent in occupations with lower physical activity, such as bus driving, compared with heavy physical activity.² Driving may be associated with decreased physical activity, elevated body mass index, low consumption of fruits and vegetables, and greater tobacco use. In 130 San Francisco taxi drivers, 35% had four or more CVD risk factors, including current smoking in 36% and no regular physical activity in 33% of the cohort. ⁷ These predispositions may also affect other gig jobs such as warehouse or factory work. Despite potential physical demands, the “on-demand” nature of gig work may promote greater sedentary behavior, erratic work hours, abnormal sleep-wake cycles, and high strain due to imposed productivity measures and stressful conditions – whether it be packing boxes or driving total strangers. Equally important, survey data suggest that workers do not feel adequately supported during the pandemic, neither by the app-based companies they work for nor by public health measures.⁸ There may be deleterious health consequences imposed by contingent work which can disappear unpredictably.

The adverse effects of established CVD risk factors may be magnified in a gig workforce due to structural barriers to care. Gig workers may not qualify for benefits that are legally mandated for wage-earning employees, including employer-sponsored health insurance, disability and occupational health protections, social security contributions, minimum wage, and the right to bargain collectively. Without these, access to preventive healthcare may be severely curtailed. Although some gig jobs in entertainment or technical fields can be lucrative, for the most part, the lower barrier to entry of gig-based jobs may attract a diverse group of workers across the spectrum of age, health, and socioeconomic position, ranging from older retired, insured individuals to uninsured recent immigrants to those working multiple jobs and living paycheck to paycheck. Gig work may overrepresent racial/ethnic minorities as well.⁹ There may be links to cultural and structural barriers to optimal cardiovascular health.

The nature of the rideshare gig economy, along with our limited understanding of this population, presents a unique opportunity for health promotion that needs to be addressed systematically. First, we must understand who these drivers are, including detailed assessments of their social, economic, and lifestyle habits and access to preventive care, to identify and prioritize their health needs. Second, because rideshare drivers rely on app-based services and user-based ratings and provide the tools necessary to complete their work (i.e. smartphone and personal vehicle), we could leverage digital health platforms and tools to comprehensively profile and link daily behaviors with digitally-derived health data. The unique health vulnerabilities of the gig economy in combination with a reliance on digital tools may facilitate the development of targeted interventions and novel care delivery models for prevention. Virtual primary care and disease-based interventions may prove particularly effective to this population who may be unable to access routine in-person primary care. Third, driver engagement, such as incentives to maintain health, could be gamified on app platforms. Engagement approaches may include providing incentives or rating for healthy behaviors such as taking a break to walk, counting steps, and engaging with a health coach. Approaches that are effective could be eventually scaled to the general population. Fourth, these interventions should be rigorously studied through practical randomized clinical trials with decentralized study designs and digital technology integration. Interventions should be “one-click”, use guideline-recommended treatment approaches, and importantly, meet gig workers where they are.

From a societal perspective, gig companies, legislators, and the public at large can also take a greater role by directly addressing barriers to health insurance and access to preventive care. In November 2020, voters in California approved Proposition 22, a ballot initiative that preserves the independent contractor status of rideshare and delivery drivers. The initiative pledges enact labor and wage policies specific to rideshare workers, including earnings minimums, shift duration limits and rest policies, and stipends based on weekly driving amounts, ranging from 41% to 82% of the average California health insurance exchange premium.¹⁰

On the surface, these measures seem positive, enabling greater health care access, at least in principle. A large new pool of insurees could spawn low-cost care models such as telehealth-first programs. However, the proposition, financed by DoorDash, Lyft, Uber, and other gig driver companies and strongly opposed by labor groups, precludes workers of access to traditional employment benefits, and included unusual provisions to make repeal or amendment nearly impossible. In August, a California Superior Court judge ruled the proposition to be unconstitutional, and the legal employment status and health benefits of gig workers remain in limbo.

In conclusion, the gig workers are vulnerable to a unique confluence of lifestyle and systemic potentiators of adverse health. We believe that working in the gig economy should be considered a new social determinant of health – and perhaps even a potentially modifiable cardiovascular disease risk factor. There is a pressing opportunity for key stakeholders – including researchers, funding agencies, gig economy employers, governmental institutions, and health policy experts – to systematically understand who the gig economy workers are, develop targeted, scalable interventions for health management, and rigorously conduct pragmatic randomized trials of such interventions for CVD and other chronic diseases.