1. Introduction
The COVID-19 pandemic has affected and continues to affect the lives of millions globally [
1]. It has negatively impacted on the health and wellbeing of populations directly through infection, as well as through serious societal and economic consequences such as unemployment and underemployment [
2]. Furthermore, there is evidence that vulnerable populations are disproportionately affected in terms of both, their health and the socioeconomic impact [
2,
3]. Individuals with increased vulnerabilities to the disease include people with disabilities, the elderly, and people living in poverty [
3]. Groups at greater risk of suffering from economic loss include those with underlying health conditions, older people, women, young persons, as well as migrant and unprotected (e.g., casual) workers [
2]. Even before this pandemic, “vulnerable workers” were recognized as those in higher risk occupations or vulnerable because of their health or socioeconomic circumstances [
4]. Therefore, someone with an underlying health condition would be more vulnerable to more serious health detriments from COVID-19, as well as being at greater risk of poverty as a result of this pandemic. Moreover, disadvantaged individuals may have lower educational attainment, have poorer health, and live at or below the poverty line [
5]. Thus, such disadvantages can compound one another. It has been argued that this compounding effect increases the likelihood of such individuals becoming vulnerable workers (for example, they may be in more insecure work) [
6].
To illustrate this, let us consider in greater detail one of these groups, namely those individuals with long term health conditions or disabilities. For example, if they had a severe respiratory condition such as chronic obstructive pulmonary disease (COPD), they could be more susceptible to serious COVID-19 complications [
7]. Such individuals, along with those suffering from many other health conditions and disabilities, could be more severely impacted by this pandemic in terms of their health and wellbeing. Furthermore, they might have to take greater preventive measures to avoid being infected (such as socially isolating themselves, especially as some workplaces may pose an increased COVID infection risk [
8]), and thus could suffer more in socioeconomic terms. Even before the pandemic, it was noted that those with disabilities and long-term health conditions were significantly disadvantaged in the workplace, sometimes facing discrimination and receiving lower rates of pay [
9]. Disability is also associated with lower educational attainment, higher morbidity, lower employment rates, and poverty [
10]. The disabled suffer further handicap in that they often need higher earnings to achieve the same standard of living as an able-bodied person [
11,
12], for example, due to their higher heating, care, and transportation costs. Therefore, if the COVID pandemic is affecting the socioeconomic wellbeing of populations globally, is it possible that those who were already disadvantaged, such as the disabled, would suffer even more than others (that is, populations not considered to be more vulnerable)?
In our opinion, occupational health (OH) professionals could provide valuable insights to this question. Occupational health is the health discipline that focuses on the interface between work and health, particularly concerning the effects of work on health and the health and fitness of individuals to work in specific jobs. Occupational health professionals include physicians and nurses, as well as others such as physiotherapists, ergonomists, and occupational hygienists [
13]. Therefore, professionals working in this field will have intimate experience of the impact of work (or lack of work) on the health of workers, including those in disadvantaged groups, in circumstances such as this pandemic. This may be the case whether the OH professional is a clinician, academic, researcher, or works at policy level, as they are all interested in this interplay between work and health. The primary aim of OH is to protect and promote workers’ health [
14]. The International Commission for Occupational Health (ICOH) is the oldest global scientific association in this field and has over two thousand members in 93 countries [
15]. We believe that the views of ICOH members would, hence, be particularly appropriate for evaluating the effects of this pandemic on vulnerable workers in the context of health and work (including unemployment and underemployment).
The aim of this study was to determine whether our respondents perceived that any groups of vulnerable workers would suffer greater detriment as a result of the pandemic, and if so, which groups.
4. Discussion
Occupational health has recently been described as “the thin line protecting the front line” in this COVID-19 pandemic [
17]. This was in the context of OH services to healthcare workers in the UK. Indeed, a significant number of papers in the OH and COVID-19 literature have pertained to frontline healthcare staff [
18,
19,
20,
21]. However, this description is likely to be apt for OH professionals in most sectors globally as they are involved in assessing, advising, and monitoring those working and aiming to return to work in the midst of this pandemic. More recent papers related to COVID-19 and work, mainly from an OH perspective, address subjects as diverse as the reporting of occupationally acquired COVID-19 in all sectors [
22] and the safe return to work of those who had been “shielding” because of COVID-19 due to possible risk factors, and of those who had contracted COVID-19 [
23]. Therefore, OH professionals are well placed to have informed and cogent opinions on which groups of workers might be or become more adversely affected by this pandemic. Therefore, although our data consists of subjective responses to our questions, we believe that the opinions of OH professionals are especially valuable in this context. To our knowledge, there has, so far, not been previously published work on COVID-19 and vulnerable workers from the perspective of OH professionals.
Globally, our responders felt that those who were either in less secure jobs, that is, in precarious employment (including low paid, “zero-hour” contracts) (79%) and informal work (such as street food vendors and waste pickers) (69%), or who were unemployed (63%), were the most at risk of further disadvantage from this pandemic. This correlates well with other available literature. For example, the International Labor Organization (ILO) describe the 1.6 billion informal economy workers as being amongst the most vulnerable in the labor market. ILO estimated a decline in their earnings of 60% globally in the first month of the pandemic, with the largest regional declines expected to be 81% in Africa and Latin America [
24]. In addition, job insecurity and unemployment are already known to be strongly associated with poorer health. Indeed, both are said to cause ill health [
25]. For example, those in insecure work are 1.25 more likely to suffer ill health and 2.5 more likely to suffer mental ill health than those in secure jobs [
26].
The next group thought to be at risk of further disadvantage were migrant workers (65%). Migrants tend to work in sectors that put them at greater risk of COVID-19 infection (such as farms and food processing facilities) [
3], but also typically have temporary or informal work arrangements, with low wages and social protection, leaving them more vulnerable to the economic consequences of this pandemic [
27] and requiring more co-ordinated responses from government agencies [
28].
Those with disabilities or long-term health problems (61%) and older workers (56%) were the next two groups that our respondents felt would fare worse in this pandemic. Even pre-COVID-19, it was noted that disabled employees in the UK were more likely to be in part-time jobs, to be paid less, and to have their employment rights infringed despite legislation intended to prevent this [
29]. It has been argued that those with disabilities are particularly socioeconomically disadvantaged (for example, that they are more likely to lose their jobs) [
30] and have had their rights further eroded [
3] as a result of the COVID-19 pandemic. Similarly, older persons can face worsening of their socioeconomic situations, especially those who are poorer and socially excluded. Previous pandemics (such as MERS) led to higher unemployment and underemployment in older workers as compared with younger workers. In addition, it is reported that COVID-19 is escalating age discrimination and stigmatization [
31].
Only 21% of respondents thought that women workers would suffer further disadvantage from the pandemic. This is maybe surprising as women are overrepresented in lower paid and unprotected jobs [
26]. Moreover, the economic downturn in the service sector is said to be a further contributor to the disproportionate effects of COVID-19 on women workers [
32]. It is unlikely that the demographics of our respondents (52.7% male to 46.7% female) would explain this finding. One possible explanation could be that women workers are not traditionally listed as one of the groups of “vulnerable workers” (such as in [
4]). However, current evidence [
26,
32] suggests that OH professionals should be more cognizant of this group’s particular vulnerability to the socioeconomic effects of this pandemic.
When we look at the continental pattern of responses to Q22, although we note many similarities between the continents, we also see some interesting differences. Precarious work features at or near the top for most continents (Africa 86%, Asia 62%, and Europe 83%). In contrast, those working in the informal sector were more likely to be considered to be a vulnerable group in Africa (86%) than in Europe (60%) or Asia (58%). This may reflect how those in this sector are organized. For example, it is possible that more workers are in this sector in Africa than in Europe. However, this may not fully explain the difference in perception of vulnerability, given that there are likely to be many in this sector in Asia and they were not rated there as being a more disadvantaged vulnerable a group as compared with migrants (73%) or those with disabilities (62%). Indeed, in Asia, migrants (73%) were the most likely to be considered further disadvantaged by COVID-19. This may reflect the nature of workforces on the Asian continent, as well as there being little or no structural support for this group of workers. Women (8%) and the unemployed (42%) were the two groups the least likely to be rated to be further disadvantaged in Asia. As noted in the global section of our analysis, women were generally not thought to be further disadvantaged, and this was reflected in the continental figures, i.e., Europe 29% and Africa 8%. As we commented above, this does not reflect concerns in the current literature that women are a particularly vulnerable group in these COVID times and may be a learning point for OH professionals. Responses related to disability were consistent across the continents, i.e., Africa 62%, Asia 62% and Europe 60%. The responses related to older workers were similar from Africa (58%) and Europe (60%) but were lower from Asia (42%).
In reply to Q22, globally, the majority (67%) believed that their government could take actions to mitigate the effects of the pandemic in these already disadvantaged groups. Amongst the three continents with the most responses, those from Africa and Europe were similar (62%) and the highest number believing that their governments could take mitigating measure were from Asia (89%). Taken in isolation, Q22 could be ambiguous, as it would not be clear, for example, whether respondents thought that their governments could take further actions because not enough had been done so far, or whether the respondents thought their governments had already taken action but there was more that could be done. However, the real value of Q22 was to elicit the qualitative responses to Q23. We wanted to see what our respondents might suggest in terms of actions their governments could take in this context.
In response to Q23, we were particularly interested by those suggestions of fundamental reviews of inequalities and discrimination that lead to some populations being more disadvantaged and leading to their greater susceptibility to pandemics. This resonates well with other published papers that have examined this aspect of the pandemic. For example, we note that inequities in terms of race and ethnicity [
33] and other societal inequalities [
3] lead to worse health outcomes in this COVID pandemic. The multidimensional nature of disadvantage in this context, which includes poverty, poorer health and education, less secure work or unemployment, multifaceted discrimination, and lack of social support, leads to various vulnerable populations suffering much worse effects from the pandemic in terms of both their health and their ability to work [
11]. In turn, economic loss can lead to poorer health (for example by not being able to afford adequate nutrition) and poorer health can lead to a decreased ability to work. These vicious cycles between work and ill health are especially acute in disadvantaged populations and made even be worsened by the health and socioeconomic impacts of this pandemic. We believe, therefore, that enlightened approaches to recovery from this pandemic should not merely aim for a “return to normal”, but rather, seek to ameliorate the situation for disadvantaged populations in a lasting way. For example, a United Nations Development Programme (UNPD) report [
34] on recovery from the COVID crisis noted that responses should be multidimensional, be viewed through an equity lens, and focus on people’s long-term capabilities. The UNDP uses the capability approach [
35], which is an economic theory that places as its central focus the individual’s capabilities (what an individual is able to be and do) and “functionings” (this is a term used in the capability approach and means “what the individual is able to achieve in terms of her capabilities”). This UNDP report also highlighted the plight of those in precarious employment in this pandemic, such that government responses must “reach those weak links of the social and economic fabric as well as those who have already been left behind, supporting their basic capabilities and enabling subsistence” [
34]. It encourages policies enabling social protection in ways that that reduce existing inequalities and that empower individuals to achieve their development. In the capability literature, health is seen as a prerequisite to achieving one’s other capabilities [
36] and the ability to live a life that one values [
37], and therefore maintaining and protecting the health of vulnerable populations is especially important in the midst of a pandemic. One should also note the importance of addressing disadvantage in ways that respect the individuals concerned [
26]. Indeed, it has been argued that this current pandemic has offered us the opportunity to learn to do this [
38].
This study has some strengths and weaknesses. On the positive side, it was a cross-sectional survey done at the height of the pandemic, therefore, it provided us with time-sensitive information from a relevant period (May 2020) during its unfolding of the pandemic. It also captured data from different countries, which allowed us to make regional comparisons (by continent). However, we do not have a denominator, that is, the number of possible respondents who could have completed the survey. Nevertheless, authors of a survey in a comparable context argued that the lack of denominator did not impact on their outcome [
39] and we agree with them. We do not believe that this affects our findings either. Another criticism that could be levelled at our survey is that we are reporting subjective opinions. We have argued above that OH professionals are uniquely placed at the interface of work and health. Their active involvement in this pandemic [
17], therefore, provides us with valuable insights from arguably the group most conversant with our survey questions. We also note that we had not made it explicit in Q21 whether we meant vulnerability to further health or socioeconomic deterioration. It is the latter deterioration that was the focus of our interest. It is possibly fortunate that our colleagues interpreted the question as we meant it, as we can infer by their responses in Q23, which all describe socioeconomic solutions or strategies. Nonetheless, if this survey were repeated in the future to assess whether OH professionals’ views had changed in time, it would be preferable to specify “socioeconomically disadvantage” in Q21. A future study might also clarify Q22 further by having different parts to this question, for example, by asking respondents first whether they thought their governments were already taking relevant mitigating actions. Nonetheless, in our study, we were more interested in using Q22 as a preamble to the qualitative free-text replies to Q23, so we do not feel that the current wording of Q22 had a detrimental impact on our study findings. However, the methodology used, which was a bespoke questionnaire (as there is no validated questionnaire that would have elicited the information of interest) and the low numbers in our study, limit the generalizability of our findings.
