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Berger M. COVID-19 highlights need for more discussion about defining “essential workers”. HPHR. 2024;86.
Throughout the COVID-19 public health emergency (PHE), from 2020-2023, advertisements and news stories proliferated about the important role of ‘essential workers’ to maintain the health care system and broader economy.1-4 But just who were these essential workers? The answer to that question depends on who you asked—and when.
The Cybersecurity and Infrastructure Security Agency (CISA), part of the U.S. Department of Homeland Security, for example, issued guidance as early as March 2020 that defined essential workers as those associated with critical infrastructure sectors, such as health care, energy, transportation, public works, communications/information technology, first responders and other “Community-Based Government Operations and Essential Functions” ranging from “Federal, State, and Local, Tribal, and Territorial employees who support Mission Essential Functions and communications networks” to “Hotel Workers where hotels are used for COVID-19 mitigation and containment measures. This CISA definition was from the PHE’s outset expressly relied on by the Centers for Disease Control and Prevention (CDC) among others.6
When CISA published its fourth version of its essential workers guidance in August 2021, it had expanded from 11 pages to 237. The new guidance included more detailed description of workers in each of these categories, discussed the nuances of defining essential workers, and mentioned new occupations, such as elder and childcare, not expressly identified in earlier guidance. While some states (21 according to the National Conference of State Legislators) largely relied on CISA’s guidance during the COVID-19 PHE, 23 states adopted their own varying definitions.8
As the vaccine rollout began in 2021 and governments developed prioritization schemes for what was initially a vaccine shortage, the definitions of essential workers evolved once again.9 Even within the various categories of essential workers, such as the retail sector, there was much debate during COVID-19 about which specific businesses or workers were rightly deemed essential .10-12 By 2023, about one-third of American workers were deemed essential by their employers based on various national, state, or private company criteria and definitions.13
While some essential workers such as physicians and traveling nurses may have been highly paid, on the whole workers deemed essential were more likely than their employed ‘non-essential’ counterparts to be racial and ethnic minorities, have lower incomes (<$40000) or lack a college education. As explained in October 2021 by the Presidential COVID-19 Health Equity Task Force “[b]arriers to employment, familial wealth accumulation, and education result in Black and Brown people disproportionately holding essential occupations that carry higher risks of exposure to COVID-19, in part due to inadequate protective equipment.”13,14
Being designated an essential worker had both benefits and drawbacks. On the one hand being deemed ‘essential’ might mean that a worker would receive a COVID-19 vaccine earlier (at least in those states that followed recommendations) or perhaps prioritization for receiving personal protective equipment (PPE) (when such equipment, often in short supply even in the health care sector, was in fact available).15-17 In some cases, state triage guidelines even took occupation or essential worker status into consideration in defining critical care priorities.18
But being an essential worker also sometimes meant more stress, burnout, risk of contracting illnesses and negative interactions with members of the public, with such challenges perhaps especially acute within the health care field.19-23 Those such as community and social services and transportation workers faced especially heightened mortality risks.24
Some essential workers such as some grocery store workers that were not reflected in their salary or benefits or put their health at risk, sometimes with health measures like mask wearing frowned up, to maintain or bolster company profits.25-26 While some workers received higher ‘hero’ or other pay (at least temporarily) this was not guaranteed. Workers did not typically have input into whether or not they were designated essential. As well many essential workers often also lacked paid time off to seek vaccination or other medical care.14 Essential workers from health care providers to grocery store workers also found themselves dependent on others such as child care workers, who themselves were designated as essential workers and even before COVID-19 had been the subject of bipartisan reform efforts.27-29 Early in the pandemic observers noted that, taken in aggregate, essential workers, such as those in nursing homes or food services, were disproportionately women and minorities and often poorly compensated.30-32
As expansive as definitions of essential worker often were, not all workers who performed important tasks were included in these designations. For instance, mental health and substance use disorder workers along with other providers were not defined as essential when it came to early access to vaccination and PPE.33-34 Controversies proliferated at the state level about what types of private businesses were or were not “essential.”35 Many small businesses, for instance, were subject to lockdowns, while larger warehouse-style retail facilities, received essential status, enabling them to maintain or increase sales and staffing levels during the height of the epidemic.36-37 Mothers and other caregivers taking on increasing responsibilities as schools and businesses closed or shifted to virtual approaches were not recognized as ‘essential, much less compensated for their additional work.38
In an increasingly complex society with, as CISA has recognized, numerous interdependencies and so many workers deemed ‘essential’, the concept of the essential worker for the purposes of emergency planning and response warrants further discussion.39
Even from a a strictly utilitarian viewpoint, policies designating some but not others as ‘essential’ contributed to confusion and may have made it more difficult to curb COVID transmission. The definition of essential worker extended well beyond health care workers and first responders. High-profile outbreaks such as those tied to meatpacking facilities or retail settings, placed at risk workers and their communities.12,40-43 Efforts to protect workers such as ensuring access to personal protective equipment and training, ensuring benefits such as sick leave and child care and efforts to reduce infectious disease transmission in the workplace are essential.40-43
More broadly, predicating receipt of life-saving care based on an individual’s occupation could be viewed as one more reflection of the ‘lifeboat ethics’ at times associated with of the nation’s approach to COVID-19.44 A similar line of thinking led to discrimination at times during the pandemic against persons with disabilities in crisis standards of care whose lives were viewed even by health providers as being less important than others viewed as performing ‘essential’ roles.45-4
Despite the calls of such groups as the Presidential COVID-19 Health Equity Task Force, which in its 2021 report called for such steps as ensuring essential workers have paid time off to receive vaccinations, working with unions and others representing essential and frontline workers—and similar calls from others for more attention to worker health following COVID-19—few concrete changes appear to have been made.47 For s the pandemic or at least the urgency once associated with it recedes, some essential workers now are experiencing post-COVID19 complications and disabilities in part due to the higher risks of contracting COVID-19 that they faced during the PHE.48
Looking back at the COVID-19 PHE response underscores the need to better understand the composition of the ‘essential’ workforce, how it is defined and by whom, and how these definitions are implemented by federal, state, local, tribal, and territorial governments. There is a need to understand better the impacts of being designated essential, as well as who is excluded from this definition and why. While the discussions over who is deemed essential with respect to COVID-19 have now been largely tabled, recent reports of H5N1 (bird flu) and increased potential risks to agricultural workers, often lower paid and lacking personal protective equipment, underscore the continuing importance of confronting these issues as well as centering equity in the nation’s preparedness and response.49 A starting point may be to reconsider the recommendations of the Presidential COVID-19 Health Equity Task Force as well as those of the 2022 Federal Plan for Equitable Long-Term Recovery and Resilience (ELTRR) for Social, Behavioral, and Community Health intended to “strengthen the vital conditions necessary for improved community and individual resilience, and well-being.” 50 Collection of additional occupational health data, 51 funding for research to further study the occupational health implications of disasters and emergencies, and perhaps most importantly, broad and direct public participation in planning and discussions about issues that directly impact essential workers and others can help ensure the lessons learned from COVID-19 are reflected in the nation’s future pandemic responses.52
The author gratefully acknowledges the input of an anonymous peer reviewer. However, the opinions expressed are solely those of the author and should not be imputed to other individuals nor to any public or private entities.
Mitchell Berger, MPH, JD, has worked at the federal level and for local public health departments.
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