Reflect on chapter 4 below !!! Black

Reflect on chapter 4 below !!! Black Lives Matter Structural Racism, Sexism, and Carework in the United States ODICHINMA A KOSIONU, JANET TE DILL, MIGNON DUFF Y, AND J’MAG KARBEAH Facing simultaneous crises of COVID-19 and nationwide protests in response to the high-profile police killings of Breonna Taylor, George Floyd, and many others—the continued impact of anti-Black racism in the United States was laid bare during the pandemic. There was widespread media attention to racial disparities in infection and mortality rates, with the Centers for Disease Control and Prevention reporting in August 2020 that Black non-Hispanic Americans were 2.6 times as likely to contract the virus as white non-Hispanic Americans. Even more alarming, Black women in the United States were 4.7 times more likely to be hospitalized for COVID-19, and their risk of death was more than double that of white Americans (Centers for Disease Control and Prevention 2020a). This chapter argues that these differential impacts must be understood in the context of Black women’s unique position in the health care workforce, a product of structural racism and sexism. Leading into the pandemic, 23 percent of all Black women in the U.S. labor force worked in health care, meaning that almost one in four Black women were at the epicenter of risk during the COVID-19 crisis.1 Black women are more overrepresented than any other demographic group in health care, and within the sector they are most heavily concentrated in some of its lowest-wage and most hazardous jobs. The position of Black women in health care has its roots in the same devaluation of Black bodies that is reflected in police brutality and killings of Black men and women. Importantly, the risks to Black women working in hazardous low-wage health care jobs that lack benefits such as paid sick days did not begin or end with the pandemic. Solutions must reach beyond the impact of the COVID-19 virus to directly address the underlying inequities and inadequacies stemming from the intersections of structural racism and sexism. Public and private investment in the carework infrastructure in the United States is therefore key to creating racial and 4 Black Lives Matter 37 gender justice as well as to providing safe and high-quality care to all beyond the public health crisis of COVID-19. Black Women, Health Care, and COVID-19 As Julie Kashen argues (chapter 20, this volume), paid carework in the United States reflects a hierarchy of human value in which we value the lives and contributions of some people over those of others. The intersection of anti-Black racism and sexism has led Black women to be particularly affected by these racialized and gendered hierarchies. The racialized division of labor between white and Black women in the performance of overwhelmingly feminized carework has its roots as far back as chattel slavery. Scholars note that throughout history this division of labor channeled white women to become masters of the emotional, more performative aspects of carework, whereas Black women were forced to engage in more invisible “backroom” and physically intensive tasks (Duffy 2011; Glenn 1992, 2010). In the context of slavery, white women of means were the hostesses and mistresses of the home, while Black enslaved women often did the backbreaking and never-ending work of cleaning houses and outhouses, laundering and maintaining clothing, and procuring, preparing and serving food. Domestic servitude in the North in the pre-Civil War era mirrored this gendered and racialized division of care labor, despite the different economic structure, and Black women were heavily overrepresented in the expanding ranks of domestic servants across the nation in the second half of the nineteenth century (Duffy 2011; Glenn 1992, 2010). As the ranks of domestic servants began to decline in the early twentieth century, the modern health care system was being created in the United States. The professionalization of medicine meant that physician jobs were increasingly closed to women (Ehrenreich and English 1979). White women activists carved out the niche of trained nursing as a “feminine” domain by focusing rhetorically on the moral and spiritual caring aspects of the job (despite the reality of hard physical labor for many nurses at that time), and Black women were largely excluded from professional nursing well into the 1960s (Hine 1989; Reverby 1987). The development and explosive growth of a wide range of low-wage health care support roles began in earnest in the second half of the twentieth century, and these jobs have been disproportionately held by women (and smaller numbers of men) of color as well as immigrant workers (Duffy 2007). Women of color are heavily concentrated in these roles that constitute the “dirty work” of care—direct care for older, disabled, and ill bodies and bodily functions as well as cleaning and food preparation and serving in hospitals and long-term care institutions. The gendered and racialized stratification of health care, created by an interplay of structural exclusion and cultural association, mirrors the division of labor first created during slavery, and places Black women in a very particular high-risk position. 38 AKOSIONU, DILL, DUFFY, AND KARBEAH Going into the pandemic, women were heavily overrepresented across the health care sector, making up 77 percent of health care workers overall, 83 percent of workers in skilled nursing facilities, and 86 percent of home health workers (table 4.1). Within this extremely female dominated workforce, Black women were overrepresented at higher rates than any other group. While Black women made up only 6 percent of the overall labor force in 2018, they made up almost 13 percent of the health care industry overall and 22-23 percent of workers in home health care services and nursing care facilities (table 4.2). These rates of representation are more than 3.5 times their rate of representation in the labor force. So, although white women are the numerical majority in health care, Black women workers are more highly concentrated in these low-wage, high-risk jobs. In fact, as mentioned earlier, almost one-quarter of Black women worked in health care in the years directly preceding the pandemic. It should be noted that other groups of women of color are also overrepresented in the health care sector. For example, Hispanic women are overrepresented at a rate of about 1.3 times their representation in the labor force in the health care sector (10.1% of health care workers compared to 7.8% of the labor force). Asian women are overrepresented at a rate of about 1.7 times their representation in the labor force (5.2% of health care workers compared to 3.0% of the labor force). While women from other racial groups are overrepresented it is not to the same degree that Black women are concentrated in the industry, and not with the same kind of widespread representation across subsectors and occupations. The TABLE 4.1 Health care industry by sex Industry Total number of workers % Male % Female Labor force 166,063,647 52.7 47.3 Total health care 18,562,557 23.0 77.0 Home health care services 1,543,212 13.7 86.3 Hospitals (except psych) 7,398,455 25.0 75.0 Nursing care facilities (skilled nursing) 1,875,203 17.2 82.8 Residential care (except skilled nursing) 1,165,336 24.7 75.3 Medical offices, outpatient centers, and other health care services 6,580,351 24.4 75.6 Note: Calculated by authors from American Community Survey 2018 (Ruggles et al. 2022). Includes only workers in the labor force. Black Lives Matter 39 health care sector is further gendered and racialized in the distribution of jobs within the industry (table 4.3). Black women and white women are overrepresented in almost every major occupational category in health care, with only two exceptions. Women overall are underrepresented among physicians and surgeons, where white men make up a large segment of the workforce. And white women are also underrepresented among janitorial and housekeeping workers, a heavily racialized sector where Black men are also overrepresented. The three occupations in which Black women are most heavily concentrated are licensed practical nurses; nursing, psychiatric, and home health aides; and personal care aides (see table 4.3). This is a group of jobs that is often referred to as direct care, emphasizing the hands-on nature of the care provided by these workers to older adults and people with disabilities in private homes and in institutional settings. In the first waves of the pandemic, nursing home workers were considered to have “the most dangerous jobs in America” because of the high incidence of COVID-19 cases and deaths (McGarry, Porter, and Grabowski 2020). TABLE 4.2 Health care industry by sex and race Industry % Black female % White female % Black male % White male Labor force 6.3 28.9 5.6 32.6 Total health care 12.8 (2.0 ×)* 46.9 (1.6 ×) 3.3 13.7 Home health care services 23.7 (3.8 ×) 38.9 (1.3 ×) 3.1 6.1 Hospitals (except psych) 11.2 (1.7 ×) 47.7 (1.7 ×) 3.6 14.5 Nursing care facilities (skilled nursing) 22.5 (3.5 ×) 45.9 (1.6 ×) 4.5 8.8 Residential care (except skilled nursing) 18.5 (2.9 ×) 42.0 (1.5 ×) 6.2 (1.1 ×) 13.7 Medical offices, outpatient centers, and other health care services 8.3 (1.3 ×) 49.0 (1.7 ×) 2.2 15.9 Note: Calculated by authors from American Community Survey 2018 (Ruggles et al. 2022). Includes only workers in the labor force. Note that percentages do not add to 100 because not all groups are included in the table. These racial categories include only Black non-Hispanic and white non-Hispanic workers. * Represents rate of overrepresentation. TABLE 4.3 Occupational breakdown within health care by sex and race Occupation % Black female % White female % Black male % White male Labor force 6.3 28.9 5.6 32.6 Medical and health services managers 9.7 (1.5 ×)* 47.6 (1.6 ×) 3.3 19.3 Physicians and surgeons 2.7 21.8 2.6 42.3 (1.3 ×) Registered nurses 9.8 (1.6 ×) 62.4 (2.1 ×) 1.4 7.4 Licensed practical nurses 22.5 (3.6 ×) 46.8 (1.6 ×) 3.8 5.9 Nursing, psychiatric and home health aides 29.5 (4.7 ×) 37.1 (1.2 ×) 4.0 5.1 Medical assistants and health support 14.1 (2.2 ×) 43.6 (1.5 ×) 2.8 5.8 Personal care aides 23.6 (3.7 ×) 35.7 (1.2 ×) 4.9 6.7 Food service and preparation 16.3 (2.6 ×) 33.5 (1.2 ×) 10.1 (1.8 ×) 16.6 Janitorial and housekeeping 17.5 (2.8 ×) 24.1 11.9 (2.1 ×) 17.5 Receptionists and information clerks 11.9 (1.9 ×) 55.9 (1.9 ×) 1.2 2.7 Secretaries and admin assistants 10.8 (1.7 ×) 65.2 (2.3 ×) 0.7 2.3 Note: Calculated by authors from American Community Survey 2018 (Ruggles et al. 2022). Includes only workers in the labor force. Note that percentages do not add to 100 because not all groups are included in the table. These racial categories include only Black non-Hispanic and white non-Hispanic workers. These occupational groups were chosen because they are some of the largest numerically within the field of health care. *Represents rate of overrepresentation. Black Lives Matter 41 While workers in these institutions were sometimes lauded as heroes, staff who held jobs at multiple facilities were often painted as vectors of disease (FreytasTamura 2020), racialized narratives that are similar to those used against immigrant laborers decades earlier (Molina 2011). During the first waves of the crisis, many workers in long-term care facilities did not have access to adequate personal protective equipment, and risks were exacerbated by chronic understaffing (Grabowski and Mor 2020). Home health care workers were also identified as at high risk for infection, as lacking in appropriate protections, and as potential vectors of transmission as they traveled between clients’ homes (Penton 2020). The other two types of jobs where Black women are most overrepresented are in the “back-room” positions in food service and preparation and janitorial and housekeeping (see table 4.3). These workers clean hospital rooms, serve food in nursing homes, and do laundry in long-term care facilities. Despite also being deemed essential, the labor of these workers and their role in a pandemic world of care have been less visible and received even less attention than the work of direct care. Housekeeping staff at a hospital have been exposed to COVID-19 but may have received differential access to appropriate personal protective equipment (Hong 2020). New Virus, Old Problems While COVID-19 changed almost every aspect of work and life for people around the globe, the risks faced by Black women working in health care during this crisis were a direct result of existing inequities and inadequacies. The labor of workers in care is devalued, meaning that workers earn less in these occupations as compared to occupations that require the same level of education and skill but do not involve carework (England, Budig, and Folbre 2002; Levanon, England, and Allison 2009). This is especially true for direct care and other low-wage care workers, where Black women are overrepresented, while professionalized nurturant care occupations like nursing that are more likely to have a higher proportion of white women are less likely to incur a wage penalty (Budig, Hodges, and England 2019). Additionally, studies of carework in the health care sector demonstrate that Black and other women of color experience the largest wage penalties of all women in these occupations (Dill and Hodges 2019). The long-term care sector is where Black women are most overrepresented and where we also find the lowest wages. The mean hourly wage in 2019 for home care workers was $12.12, residential care earned average wages of $12.69 per hour, and nursing assistants in nursing homes earned $13.90 per hour (PHI International 2020). Low incomes lead to high poverty among long-term care workers: one in six home care workers live below the federal poverty line and nearly half live in lowincome households. More than half of home care workers receive some form of public assistance, and nearly half rely on means-tested Medicaid coverage for health insurance. Direct care workers in institutional settings (either residential care or nursing homes) are slightly more advantaged than home care workers, but nearly half of these workers live in low-income households, more than a third receive some form of public assistance, and around a quarter rely on Medicaid for health insurance (PHI International 2020). A recent research study found that among Black and Latina female direct care workers specifically, about 50 percent earn less than $15 per hour, and only 10 percent have employer-based health insurance coverage (Himmelstein and Venkataramani 2019). Direct care and cleaning and food workers also fall into the low-wage group that has the least access to paid leave, with estimates ranging from one-fifth to one-third having any access to paid leave for illness or to care for a loved one (Kinder 2020). In fact, some health care workers were even exempt from the emergency COVID-19 paid sick leave passed by Congress because of worker shortages (Long and Rae 2020). Low wages and lack of benefits are deeply problematic for Black women and others working in direct care and other low-wage jobs in the health care sector (True et al. 2020). Living in poverty increases the risk for many chronic diseases as well as exposure during a pandemic like COVID-19 (Conway 2015; Kinder 2020; Nguyen et al. 2020). Workers in this labor force often work multiple jobs to cobble a living wage together, which became a barrier to containment during the crisis (Baughman, Stanley, and Smith 2020; Van Houtven, DePasquale, and Coe 2020). And lack of access to appropriate medical insurance and adequate paid leave policies both cripple individual workers and undermine larger public health efforts. Direct care and cleaning and food service jobs in health care were hazardous long before the pandemic brought the dangers into public view. Health care workers have the highest rates of workplace-related injuries compared to other sectors in the United States (Gomaa et al. 2015). Within the workforce, nurse aides and nurses, who are overwhelmingly women, are much more likely to experience workplace-related injuries and stress compared to other health care workers (D’Arcy, Sasai, and Stearns 2012). In addition to being exposed to biological agents, such as viruses, direct care and reproductive workers in health care are exposed to toxic chemicals used in cleaning and sanitizing, heavy lifting of equipment and patients, physical and verbal assault, and a range of high-stress conditions, including long hours and night shift work (Kurowski, Boyer, and Punnett 2015). Black women are more likely to work in nursing homes and other long-term care settings that are understaffed and underresourced, leading to greater risk and exposure to injury or infection (Barnett and Grabowski 2020; Grabowski and Mor 2020). Despite this increased risk, the unique vulnerabilities of Black women in these sectors are often overlooked and necessary protections delayed—a pattern that is also mirrored in national conversations about police violence. Transforming Care, Dismantling Racism Kimberlé Crenshaw has noted that movements against police violence often highlight cases involving Black men and that similar cases of police violence against 42 AKOSIONU, DILL, DUFFY, AND KARBEAH Black Lives Matter 43 Black women are largely ignored (https://www.aapf.org/sayhername). Care is another critical arena in which Black women are located at the intersections of racism and sexism, and their experiences are central yet underappreciated. Investing in Black women through targeted investment in care infrastructure can begin to undermine some of the ideological constructions and structural barriers that have devalued both. There are a number of immediate steps the United States can and should take to address the inequities and inadequacies in the care infrastructure highlighted by the COVID-19 pandemic. First, we need policy to raise wages in the direct care, cleaning, and food service segments of the health care sector where workers are currently most grossly underpaid (Dill et al. 2020; Hess and Hegewisch 2019). This should start with a federal minimum wage increase that is inclusive of all workers (in the United States as in many other countries workers who work in private homes have often been excluded from fair labor legislation). A recent study estimated that increasing the minimum wage to $15 would result in a reduction of household poverty rates among female health care workers by up to 27 percent (Himmelstein and Venkataramani 2019). In the United States, many long-term care facilities and home health care programs are funded by federal and state governments through Medicaid and other programs. In order to ensure that wage increases do not further exacerbate staffing shortages, the rate at which facilities are reimbursed for patient care in these programs must also be adjusted accordingly. Increasing wage levels is a critical component of reimagining health care workforce policies to center social justice (Hess and Hegewisch 2019). Second, we need public policy that addresses the problematic working conditions of low-wage jobs in the health care sector in which Black women are concentrated. Protective equipment, including not only infection control but also lifting assist devices and other interventions, must be provided to workers across occupational categories, and workers should have access to predictable schedules and reliable hours (Harknett, Schneider, and Luhr 2022). All health care workers, including those who work in private homes, must be fully integrated into federal and state worker safety standards. Health systems currently lack incentives to address the quick turnovers that happen due to these high-stress, low-wage jobs that have inconsistent work hours (McDermott and Goger 2020; True et al. 2020). Direct care and other low-wage workers in hospitals and long-term care facilities need better career growth pipelines. In addition, Black workers who oftentimes provide culturally sensitive care should be compensated for the extra care they provide, in addition to creating a healthy work environment, free from experiences of discrimination and microaggressions, where they can thrive (Travers et al. 2020). Finally, health care workers at all levels, including those who work behind the scenes in kitchens and housekeeping, must be provided with sufficient paid sick leave and paid care leave (Addati et al. 2018; Hess and Hegewisch 2019). The United States lags far behind other countries in the provision of paid leave to workers across the board, and this pandemic has highlighted the costs to all of us of workers not being able to stay home when they are ill or caring for an ill family member. All of these interventions will cost money. But this pandemic has shown us that public and private sector investment in care infrastructure is not only important but imperative (Poo and Shah 2020). Black women and others who do these essential jobs in health care deserve to be paid fairly and protected fully. Beyond that, we have seen more starkly than ever during this public health crisis that we are all compromised in terms of our health and well-being when health care workers are not adequately paid and protected. And, finally, the national reckoning with systemic racism in the United States that has emerged simultaneous to the pandemic requires us to address the gendered and racialized inequities in care to move toward gender and racial justice. NOTE 1. Unless otherwise cited, all statistics were calculated by the authors using the 2018 American Community Survey (Ruggles et al. 2022). Note that we define health care broadly to include long. Respond to the two paragraphs below 1. Chapters 4 and 5 of our book dig into the impacts of Japan’s aging population on its economy and citizens. These chapters touch on Japan’s new policies to support the older generations that are working, to keep them working. Strategies such as extending the retirement age and implementing age-free work environments are brilliant and provide a good framework for other countries to deal with this shortage of workers. I did think it was interesting that despite these older workers having more advanced skills, they were still subject to lower-wages or mindless jobs. It is important for the economy to keep the aging population working, but it should be done in a beneficial way for these employees. 2. Chapters 4 and 5 discuss Japan’s recent policies and its effects regarding their strategy to extend the retirement age in order to increase labor force participation among older workers. The 2004 Amendment of Law redirected the Tienen rule to extend retirement rule, a method that majority of firms have adopted (85%). Yet the questions remains if this has societally been accepted as older workers generally work due to personal economic reasons. The policy reforms have definitely had positive effects as labor participation has increased overall, but many argue that the developments for extended retirement age goes hand in hand with the ‘virtuous cycle of active aging’. This would explain why Japan has one of the largest populations of older citizens and would also explain why they would be one of the first nations to address the stigma and challenges of older workers in the workforce. Personally, I believe that the elder population should not be subjected to work in order to preserve the quality of life, especially in order to continue living comfortably in your native country. In a way, the ethics of these developments are another conversation entirely if nations want to keep their citizens healthy throughout life in order for them to work longer than exiting the workforce at earlier ages. 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