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November 16, 2020

Health Care Workers Deserve Better Protections From Coronavirus Disease 2019

Author Affiliations
  • 1Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
  • 2Center for Public Health Law and Policy, Sandra Day O’Connor College of Law, Arizona State University, Tempe
JAMA Health Forum. 2020;1(11):e201390. doi:10.1001/jamahealthforum.2020.1390

It’s a grim reality. Included among the 232,000 deaths in the US attributable to coronavirus disease 2019 (COVID-19) are more than 1336 physicians, nurses, environmental staff members, technicians, orderlies, emergency medical technicians, and other health care workers.

Deaths of health care workers of COVID-19 are a testament to their ethical duties and heroic frontline efforts despite profound risks. Yet they are also an illustration of legal and policy failures to protect them from harm at their workplaces. This is not just a question of injustice for health care workers; it is a risk for every American person. If health care workers are not sufficiently protected and walk away from their jobs, no one will be there to care for sprained ankles or heart attacks. This has happened before, during the response to severe acute respiratory syndrome in 2003 and West African countries’ handling of the Ebolavirus epidemic in 2014. It is likely that more people died of lack of routine care in Liberia than Ebolavirus disease.1 So it is not just health care workers’ lives at stake but rather all of ours.

The actual numbers of health care workers who have died of COVID-19 may be much higher. No one really knows, because no one is officially counting. The US Centers for Disease Control and Prevention (CDC) keeps a partial tally but admits that it is a vast undercount. On November 2, 2020, the CDC reported 202 241 health care workers infections and 785 deaths based on a meager 22.7% of case reports listing deaths by occupation. By extrapolating these data, the actual number of deaths of health care workers to date could be almost 3500. In comparison, in 2017, the US Bureau of Labor Statistics reported only 146 deaths of health care workers for the entire year, with one-third resulting from vehicular crashes.

In risky workplaces hazardous to human health, federal and state safety oversights are manifold. The Occupational Safety and Health Administration (OSHA) seeks to “ensure safe and healthy working conditions for working men and women by setting and enforcing standards.” In multiple industries, OSHA receives reports, launches investigations, and sets substantial fines for violations.

Yet, for months, OSHA failed to issue meaningful and specific COVID-19 regulatory standards to protect health care workers and did not report any inspections to assess health care workplace safety.2 OSHA also typically tracks workplace deaths and injuries. Yet, on May 19, it made reporting of COVID-19–associated deaths voluntary, stating that it was too difficult to determine the “work-relatedness” of such deaths. This guidance includes work-associated COVID-19 deaths among health care workers, despite categorizing much of the health care environment as having “very high exposure risk.” OSHA has been sued by multiple industries demanding greater oversight on COVID-19 risks and only began consistently issuing COVID-19–associated health care workplace safety citations in September 2020.

Determining how health care workers are infected with COVID-19 is fraught with practical and legal complications. Was a nurse infected treating patients at the hospital or at home, by their school-aged kids? Did an emergency medical technician contract COVID-19 during a 911 response or at the grocery store later that day? Questions like these legally matter when ascertaining risk, assessing liability, and determining responsibility.

Legal complications, however, should not overshadow national commitments to prevent health care worker exposures overall. No one should be required to risk their life for a job without optimal, available health protections. Under Minnesota state law, “an employee acting in good faith has the right to refuse to work under conditions which the employee reasonably believes present an imminent danger of death or serious physical harm,” including COVID-19 exposure.

Ensuring the health and safety of frontline health care workers is essential to securing their performance over the long term. Guidance by the National Academy of Science on COVID-19 vaccination allocation strategies places health care workers involved in direct patient care at the top of the list.3 Universal support for greater surveillance of risks in health care settings is also emerging. Federal legislation has been proposed to revamp public health surveillance activities. The CDC’s "right-to-know” policies support communication of at-work exposures to relevant personnel, as long as disability and privacy rights of affected workers are respected.

The CDC and several states have implemented or recommended affirmative paid sick and safe time requirements to assure health care workers affected by COVID-19 are not rushed back to work. Still, when Congress passed the Families First Coronavirus Response Act on March 14, it allowed health care companies to exclude health care workers from these benefits. One federal district court in New York struck down an overly broad application of the law in August 2020.

States have proposed other positive interventions. Workers’ compensation benefits for at-work injuries or deaths are often tied to proof of work-associated exposure. Several states, including Louisiana, Massachusetts, Ohio, and Pennsylvania, however, support a presumption of at-work infection with COVID-19 to assure benefits for affected workers. Minnesota’s legislature expressly clarified that health care workers infected with COVID-19 are entitled to benefits. Stronger workers' compensation benefits tend to lead to enhanced work-associated safety measures, including access to adequate personal protective equipment.

Until widespread availability of safe and effective vaccines emerge to quell the threat, legal and policy interventions are key. Federal agencies must align with state and local actors to require reporting of workplace exposures of health care workers to COVID-19 via surveillance funded and coordinated by OSHA and the CDC. Workplace safety measures designed to limit exposures are essential. If health care workers are exposed, legal paid sick and safe time provisions must protect their positions while they adhere to quarantine or isolation requirements. When health care workers become infected, federal and state workers compensation laws should require employers to extend protections instead of seeking to avoid claims.

The number of health care worker deaths tied to the COVID-19 pandemic over the 9 months between February and October 2020 is likely more than half of all occupational deaths in the United States in 2017. Abating these deaths is critical to continued national preparedness and response.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Thomas D. Kirsch, MD, MPH, Department of Emergency Medicine, George Washington University School of Medicine, 2120 L St NW, Ste 450, Washington, DC 20037 (tdkirsch@gmail.com).

Conflict of Interest Disclosures: None reported.

Brolin Ribacke  KJ, Saulnier  DD, Eriksson  A, von Schreeb  J.  Effects of the West Africa Ebola virus disease on health-care utilization—a systematic review.   Front Public Health. 2016;4:222. doi:10.3389/fpubh.2016.00222PubMedGoogle ScholarCrossref
US Department of Labor, Occupational Safety and Health Administration. Guidance on preparing workplaces for COVID-19; OSHA 3990-03 2020. Published 2020. Accessed November 9, 2020. https://www.osha.gov/Publications/OSHA3990.pdf
National Academies of Science, Engineering, and Medicine. Framework for equitable allocation of COVID-19 vaccine. Published 2020. Accessed November 9, 2020. https://www.nap.edu/catalog/25917/framework-for-equitable-allocation-of-covid-19-vaccine
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