Vol. (TBD) No. (TBD) , 2020 (pp. TBD) Journal of Concurrent Disorders COVID-19 and Healthcare Workers’ Struggles in Long Term Care Homes Iffath Unissa Syed1, Farah Ahmad2 1 Department of Health Policy and Health Equity, School of Health Policy and Management 2 Department of Health Policy and Health Equity, School of Health Policy and Management For correspondence: Dr. Iffath Unissa Syed Department of Health Policy and Health Equity, School of Health Policy and Management rd 3 Floor, Stong College, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3 Phone/Fax: (416)961-5612 Ext. 222 Email: iusyed@yorku.ca Abstract Historically, research of long-term care (LTC) has focused on a number of issues, such as management structures, the quality of care for aging residents, and the gendered nature of care work, among other things. However, there is limited knowledge about how care work is relevant to (and embedded within) the realm of public health. The COVID-19 pandemic has recently exposed that residents and staff are both vulnerable to infection, morbidity, and mortality. A closer examination of the issue reveals the deeper and systematic ways in which the occupational and social conditions of health care workers is vital to public health efforts. Our analysis of the issue reveals that the social determinants of health of care workers needs to be at the forefront in management of the COVID-19 public health crisis in Canada. Keywords: Social Determinants of Health, Health Equity, Race, Gender, Care Work. Submitted: June 5, 2020 Revised: July 7, 2020 Accepted: Sep 23, 2020 Journal of Concurrent Disorders COVID-19 and Healthcare Workers’ Struggles in Long Term Care Homes The global COVID-19 pandemic has led to a ‘new normal’ of public health measures,. These measures include: physical distancing and quarantine regulations, as well as disruptions to social and public health programs, services, deliveries, and dampened workers’ health, safety, and wellbeing. Mandatory self-isolation procedures were implemented by the federal government for travellers arriving in Canada, as well as those who experience any COVID-19 related symptoms, which includes many front-line workers. Employees, specifically women in households with families and domestic care obligations have also been affected. For instance, public health nutrition programs that were offered in some public schools are less accessible as a result of the growth and implementation of e-learning in order to control the spread of COVID-19. The COVID-19 pandemic has also resulted in a significant loss of employment, which put pressure on workers as many shifted from living in multi-earner households to becoming sole earners. This resulted in added mental stress, financial and psychological pressure on workers, many of whom were already taking on extra shifts and working with multiple employers to make ends meet. Existing research shows significant mental health issues that can affect the wellbeing of long term care (LTC) staff, such as stress, depressive symptoms, and trauma (Morgan, Stewart, D’Arcy, et al., 2005; McGilton, McGillis-Hall, Wodchis et al., 2007; Astrakianakis, Chow, Hodgson et al., 2014; Woodhead, Northrop, and Edelstein, 2014; Braedley, Owusu, Przednowek et al., 2018; Syed, 2020a). Several systemic inequities have also been revealed by the pandemic, including those affecting LTC homes in Canada. Vol. (TBD) No. (TBD) , 2020 (pp. TBD) The multiple COVID-19 outbreaks in Canadian LTC homes have cost the lives of many seniors. It is estimated that 81% of COVID-19 deaths in Canada occurred in LTC homes, almost twice the average rate than other countries within the Organization for Economic Cooperation and Development (OECD) (Grant, 2020). The pandemic’s effects on care homes have also revealed and re-ignited the issues of unsafe and poor working conditions of healthcare workers, especially in the LTC sector (Syed, 2019; Arya, 2020; Bouka and Bouka, 2020; Das Gupta, 2020) with the underlying causes that present themselves as ‘cracks’ in the healthcare system and the welfare state. On April 16, 2020, a racialized personal support worker (PSW), Christine Mandegarian, died of COVID-19 after working for decades in LTC (Davidson, 2020), at a time where 621 staff members of Ontario LTC homes were infected with the virus (City News, 2020). As of June 3rd, 2020, there were almost 1,900 cases of COVID-19 among staff in Ontario LTC homes (Government of Ontario, 2020). It may have been surprising and shocking for some to note that LTC workers suddenly became the next cohort of COVID-19 victims, as well as the racialized, gendered, and precarious nature of their work. However, research has previously shown us that LTC workers are consistently exposed to unsafe and precarious working conditions (Syed, 2019; Bouka and Bouka, 2020; Das Gupta, 2020; Leslie, 2020). For example,nurses, PSWs, dietary aides, recreation therapists, and other staff often work part-time jobs in multiple locations, and can become unintentional carriers of the virus (Bouka and Bouka, 2020; Das Gupta, 2020; Leslie, 2020). These workers do not have much choice otherwise; most of these workers are not unionized, are not entitled to sick leave Journal of Concurrent Disorders benefits, and would be unlikely to stay home as a result of injury, illness, or disability, in fear of potentially losing their earnings (Bouka and Bouka, 2020; Das Gupta, 2020; Leslie, 2020). The specific socioeconomic conditions and social determinants of health (SDoH) of these workers are also often overlooked; with health officials now citing that carpooling and crowded living arrangements contribute to the rapid spread of COVID-19 among LTC workers (Bouka and Bouka, 2020). Low wages are barriers to workers’ health and wellbeing (Magnavita, 2018). Recent studies further document that LTC workers’ wage forces many to sacrifice healthy food for cheap, nutrient-deficient diets for themselves and their families (Syed, 2020b). Research shows that low wages can also drastically reduce the motivation of employees to participate in workplace health promotion programs. Poor remuneration of LTC workers leads them to work in multiple LTC facilities throughout the week in order to make ends meet- an issue that has been ignored to date because of neoliberal ideologies and policies that seek to weaken or dismantle the welfare state. The latter has been achieved, in part, by promoting certain conservative ideas and values. For example, that people are expected to (and should) work hard (Hartman, 2005), and should not be given hand-outs that could make them potentially dependent on the system, even if it means exploitation (Syed, 2015), or working precariously seven days a week, as reported in the literature investigating the working conditions of LTC (Syed, 2019). The scenario for LTC workers requires deep thought. Who would be willing to work in low-wage, dangerous, and difficult working conditions? The answer is “very few”. Vol. (TBD) No. (TBD) , 2020 (pp. TBD) Indeed, an issue which has been foreshadowing LTC homes is that there is a resource problem in LTC, with very few workers; they were under-staffed pre and throughout the pandemic (Arya, 2020). In fact, as Syed (2015) and others show, the ones who are often working in the most dangerous, difficult, and dirty jobs are often the ones who are coincidentally the most exploited – they are women, immigrants and racialized people. Indeed, the LTC sector is very much feminized, and employed predominately by racialized workers, notably employing Filipinos, and Black people, including Sudanese Dinka, Haitians, and Maghrebi people (Bouka and Bouka, 2020). Throughout the COVID-19 pandemic, the difficulty for LTC workers to manage their responsibilities have been heightened, given a shortage of personal protective equipment (PPE) and restrictions on visitors, which include unpaid and essential caregivers and family members (Das Gupta, 2020; Arya, 2020). The poor remuneration of healthcare workers, among other issues highlighted above in LTC homes, cannot be dismissed. We hold the opinion that low renumeration of many LTC workers has been one of the root causes of COVID-19 outbreaks within LTC facilities, as well as related issues of health equity, manifesting themselves as barriers to LTC workers’ health and wellbeing. Unfortunately, the issue of poor remuneration only became glaringly apparent after LTC workers became infected with COVID-19, with facility managers being unable to find adequate staff replacements due to low renumeration in comparison to the risk to personal safety – which ultimately lead to deterioration of seniors’ care. A further insult to the injury is that informal caregivers were initially banned from care homes. This ban led to a deeper care-worker Journal of Concurrent Disorders deficit which was further pronounced with COVID-19 infections at the facilities. New practices and policies have now emerged; some of which are partially helpful, but may be only masking larger, root problems within the system. For example, the Manitoba government restricted LTC workers from working in more than one LTC home (The Globe and Mail, 2020). This only prevents the potential spread from workers who are employed at multiple LTC sites. Vulnerable workers will continue to face inequities in their social determinants of health, including income and income distribution. In contrast to Manitoba, the Quebec government relaxed some of the above rules to allow previously banned caregivers access to work in their respective LTC homes (Laframboise, 2020). While this latter policy is helpful to residents, it still ignores root problems health care workers face in this sector. The temporary wage boost has been introduced by the federal government for front-line health workers is beneficial, but it is too little, too late (Ranosa, 2020). The system has taken LTC workers for granted for far too long. It is time that we permanently give LTC workers the dignity, respect, and working conditions they deserve. 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