How COVID Exposes Healthcare Deficits for Black Workers

Caroline Pryor | Yale University

Donald Tomaskovic-Devy | University of Massachusetts

The COVID-19 pandemic has revealed large cracks in our national healthcare system, particularly for low-wage and minority workers. One specific disparity is the high proportion of Black Americans and other minorities who have fallen ill or died from the disease. Using state- level data on employment and COVID infections, this report examines the link between employment in direct customer service work, COVID infection rates, and COVID-linked racial health disparities. Black workers’ disproportionate representation in frontline work, namely service work, tracks racial disparities in infection rates remarkably closely. In those states where Hispanic and White workers are more highly represented in service work, their infection rates are higher as well. These employment patterns are evidence of systemic inequality in the exposure risk associated with opening economies prematurely. Both race and essential worker status predict exposure to COVID at work, presumably accelerating community spread. Though the “epidemic within the pandemic” which affects Black communities is complex and multifaceted, it is likely tied closely to the exposure of essential workers to infection during the COVID shutdown. 

The COVID-19 crisis unfolding across America has exposed the dangers of low wage, essential jobs, jobs which are disproportionately filled by minorities. COVID cases have soared among historically disenfranchised groups, particularly  low wage earners and people of color. The Navajo Nation faces spiking cases, as do Hispanic communities. Among the latter, Hispanic cases are on the rise, while the Navajo Nation, once adjusted for population, reports more deaths due to COVID than any state, and indigenous communities on the whole are experiencing high, unchanged rates of infection. But among people of color, Black Americans are seeing particular challenges. As unemployment skyrockets and the country is gripped by calls for racial justice, statistics highlight a sustained threat: the vulnerability of Black Americans to health threats of all kinds, but especially COVID-19 infections and deaths.

Today, about one in four Black workers is employed in service jobs, the jobs most closely associated with frontline, essential work. The high proportion of Black workers in service work and low-wage sectors suggests that they are more likely to be exposed to infection. In this brief research report, we assess the possible connection between high rates of infection among Black communities and disproportionate representation in direct customer service work, and find that connection exists.

Our analysis begins by examining state variations in infections and deaths due to COVID-19 within the Black community. Next, it turns to the demographics of low-wage service workers-- those placed in high-stress, high-contact jobs. It then builds on this information by interpreting new dangers inherent in the nation’s current viral resurgence. As COVID continues to disproportionately affect Black Americans, this article examines if it is plausible that employment patterns reinforce Black, Hispanic and white infection vulnerability. We conclude by examining how we might break this cycle. 


Racial Disparities and COVID-19

Many states initially deprioritized collections of racial data on COVID-19 infections and deaths, or have only recently recognized the necessity of complete, transparent data collection. Nonetheless, it is clear that Black Americans are the hardest hit demographic in a pandemic that disproportionately affects minorities, including Hispanics and Indigenous Americans. The most recent official data shows Black and Hispanic infection rates average three times higher than those of white Americans. 

But fatality rates expose the true danger to Black Americans faced with COVID: as of July 8, Black deaths due to COVID are more than twice as high as death rates for white and Asian Americans. Adjusted for age, the Black death rate stands at 3.8 times the rate as that for white Americans, higher than for all other minority groups. As Figure 1 shows, the rate rises over 10 times in Vermont, South Dakota, and Maine. These death rates reflect both exposure to infection and comorbidity factors, such as pre-existing conditions and access to quality health care. In this report, we focus on infections, the first visible and irrefutable sign of a host of other racial inequalities revealed by the pandemic.

Figure 1: Ratio of Black to White COVID infection rates by state.[1]

Statewide trends provide a sobering picture, in which attempts to “flatten the curve” fail to provide adequate support to Black communities. As far back as April, the Washington Post warned that given the available data, majority-Black counties had three times the rates of test-positives and six times the death rates as majority-white counties. Over the course of a few months, states which first rang alarm bells about racial disparity (including Louisiana, Michigan, Illinois, and North and South Carolina, as reported by the New York Times) have not managed to drop fatality rates among Black residents to rates proportionate to their share of the population. For example, in Louisiana, where approximately a third of the state is Black, 51% of COVID fatalities in July are Black, down from a whopping 70% in April. As of late June, the state also remained in the top five states with the greatest disparity between the Black share of the population and COVID deaths. In South Carolina, where 27% of the population is Black, the COVID Racial Data Tracking Project has reported that 38% of COVID cases in July are Black, as are 44% of the fatalities. Michigan’s Black residents, just 14% of the state’s population, comprise 33% of positive cases and 41% of deaths.

Meanwhile, the APM Research Lab warns of dramatically disproportionate fatality rates between Blacks and whites in Connecticut, Michigan, and New York, with the latter standing out as a site of particularly egregious disparity for both Black and Hispanic residents. As the country turns its attention to the pandemic raging in America’s sunbelt, we must not forget the scenes of high racial disparity present even in regions where the virus is considered under control. Disparities in infection and fatality rates among Black Americans are disproportionately high, not only in new viral epicenters, but across the country.

The ratio of Black to white infections illustrates these well-known racial disparities, but also makes clear that racial disparities in COVID infections vary dramatically between states. In South Dakota, New Hampshire, and Minnesota, the Black infection rate is more than six times higher than the white rate. By contrast, in Hawaii, the Black and white infection rates are nearly identical. So, what factors might account for this extreme variance across state lines



Black Service Workers on the Frontlines

We suspected that occupational segregation, and the types of jobs Black workers are likely to hold, would offer key insight towards understanding the inequity in infections.

As most of the country shut down, essential workers, particularly low-wage essential workers, continued to go to work. Approximately 50 million of the 90 million essential jobs must report to work in person during the pandemic shutdowns. Attempts to contain infections in the workplace often forfeit protection measures for workers on the frontlines. Worse, with the exception of medical professionals, frontline workers tend to be low wage; three out of four frontline workers earn below the national average. Essential workers were at greater risk of infection, and of becoming vectors of transmission within their communities.

Our earlier Center for Employment Equity report on essential workers in Massachusetts revealed troubling vulnerabilities. Frontline essential workers report employers offering little preparation to increase safety at work, not encouraging employees to remain home if sick, and overall workers felt high levels of stress and fear for their own safety in the workplace. Seventy percent of Black essential workers reported feeling unsafe at work, a higher percentage than among white respondents, indicating that race compounds the hardships and risks faced by essential workers. What is true of essential workers in Massachusetts is likely true of service workers across the country, and this burden falls disproportionately on Black Americans as surely as do high COVID rates.

These considerations are of special concern for all frontline workers, but especially for the jobs that provide direct service to customers, where about one in four Black Americans work. We found that in states experiencing greatly disproportionate COVID rates among Black residents, service occupations are likely to comprise a sizable portion of the economy, and are more likely to be filled by Black employees. In New York, where both Black and Hispanic COVID fatalities are well above expected levels, Black Americans are concentrated in service jobs at a rate 147% above their proportion in the labor forces. In North Carolina, 40.5% of service employees are Black, twice their proportion of the population. In Louisiana, where one in three residents is Black, this number jumps to 62.3%. In Connecticut, 29.9% of Black workers are service workers, again a rate twice their population size. We can only imagine what infection or fatality rates look like in states like North Dakota, which has yet to release racialized data, but sees Black service workers overrepresented by almost 6 times their population rate.[2]

Across the country, nearly 20% of food service workers, custodial staff, and cashiers are Black. Black overrepresentation in direct customer service occupations stands well above rates for white and Hispanic workers in every state. The majority of Black service workers across the country are low wage earners, making less than $15/hour, which only increases vulnerability. We now explore whether high racial inequities in infections and high infection rates coincide with overrepresentation in potentially dangerous direct customer service jobs.

Figure 2: Excluded states are ID, ME, MT, NY, ND, UT, VT, WY[4]

Figure 2 demonstrates clearly that racial disparities in COVID-19 infection rates track Black overrepresentation in direct service occupations. In New Hampshire and South Dakota, Black workers tend to be overrepresented in direct customer service jobs by four times higher than their proportion of the state labor force. New Hampshire and South Dakota have the highest levels of racial disparity in COVID-19 infections. In contrast, in Hawaii, Black employees are no more likely to be in service jobs than other workers, and Hawaii stands out for its lack of racial disparity in infection rates between Black and white residents.  In Florida, Black service workers were overrepresented by a much smaller factor of 106.3%. Even so, at 16% of the population, they account for 22% of infections, a substantial, if less dramatic, overrepresentation among those infected. Looking across all states that report race- specific infection rates, the general pattern is quite clear: as disproportionate Black exposure to customers increases, so too does racial disparity in COVID-19 infections. 

Figure 3: Excluded states are HI, ID, ME, MT, ND, SD, UT, VT, WY [4]

As Figure 3 shows, the same pattern is present—if not quite as extreme—among recorded COVID-19 death rates in Black communities. Though these factors also influence infection rates, fatality rates are further complicated by racialized disparities in age structure, health care access, and comorbidity vulnerability, all contributing factors of medical inequity. Yet the correlation to overrepresentation in direct service positions holds, suggesting that holding essential work with high customer contact during the shutdown is a strong contributor to racial inequality in COVID-19 deaths.


White and Hispanic Service Workers

If disproportionate rates of Black COVID infections are, in part, a function of heightened exposure to infections through direct service work, the same should be true for Hispanic and White workers. In Figures 4 and 5, we look at state variation in infection rates and relative representation in direct customer service occupations for these two groups.

Figure 4: Excluded states are HI, LA, NY, ND, WV [4]

Figure 4 reports the state-level relationship between Hispanic infections and service job employment. Unlike Black Americans, Hispanic workers are actually underrepresented in direct customer service occupations in several states (Georgia, South Carolina, Mississippi, and Hawaii). Nowhere does Hispanic overrepresentation reach the levels present among Black workers in the same roles. Yet the pattern of customer service representation, exposure, and infection is similar. COVID infection rates rise among Hispanic communities when there is an increase in service jobs, and as a result, direct customer exposure. Analysts should keep this trend in mind as the Hispanic infection rate rises in many Sun Belt states.

Figure 5: Excluded states are ND [4]

Figure 5 throws systemic racial disadvantages in stark contrast. As is true for Black and Hispanic workers, in states where whites are more likely to occupy direct customer service roles, there is a tendency for the white population to share a higher proportion of COVID infections. But there is a caveat: in every state, the white infection rate is underrepresented, and whites are underrepresented in direct customer service jobs. Not only does whiteness afford a lower probability of becoming infected with COVID-19, but white workers are also consistently underrepresented in direct customer service roles across all fifty states. 


Black Service Workers and Reopening the Economy

As states begin the reopening process, infection demographics are swinging, as some note, from “blue to red”: the sunbelt remains in crisis, social events, rather than employment, are identified as a primary vector of infection, and less focus is placed on Black COVID rates. Increasing infection rates, especially among white residents, are sparking debate about whether state and local economies should reopen. In response, some states are tentatively reeling back reopening privileges.

However, secondary shutdowns will continue to rely on essential workers in customer service jobs, leaving workers, their families, and their communities exposed to new infections. As states toggle between reopening and limiting economic activity to essential workers, we must consider the possibility that service workers will repeatedly be exposed to infection, yet see stagnant paychecks in a weak economy.

With higher proportions of Black state residents in much of the sunbelt than in states like South Dakota, the demographics and relative representation of this “second wave” may lead to different infection patterns. For one thing, Southern states do not exhibit the highest rates of Black service worker overrepresentation (though neither are they among the lowest), and thus not the highest infection disparities by race, either. As visible in Figure 3, it is clear that in both the north and the sunbelt, Black workers are most often relegated to low-wage service positions, jobs which are fast swinging back to “disposable” positions, even as we treat these jobs as essential. However, as the virus grips Sun Belt states with the highest populations of Hispanic workers, infections are climbing among other communities of disenfranchised workers at alarming rates. 

Reopened economies run the risk of cementing financial disenfranchisement for Black service workers, yet congruently they disguise higher rates of infection and service employment among Black and Brown communities. The Washington Post reports that shifting demographics among COVID victims is not indicative of geography, even though the Sun Belt has higher Hispanic populations, the fastest growing infection demographic. The answer probably lies, instead, in the demographics of those whose jobs support their cities and states. As time wears on, reopened economies also threaten to explode the direct-exposure patterns identified in the previous section among states experiencing the most prolonged crises, and across multiple sectors. Those states just coming into hotspot status will enable us to gain a more nuanced understanding of direct consumer service exposure, but it is vital we recognize that potential early on. Foregrounding the experiences of service workers and individualized minority groups helps us address infection rates, but it must be consistently applied across the country. Because racial inequalities in exposure are less dramatic, the employment disparities and infection correlations in reopening states may produce lower, but still present, racial disparities, even as frontline workers of all races bear the risk associated with essential work.


Looking Forward

Health disparities—namely unequal insurance coverage, quality of healthcare, and comorbidity due to the stress of “weathering” daily racism—all increase the risk associated with infections while limiting the medical responses available to Black workers. “Weathering,” the lived experience of racial discrimination which takes a physical toll, is likely to be accelerated by the high-stress work conditions found in frontline service jobs during the pandemic. As Dorothy Roberts correctly argues, “race independently predicts hazardous locations,” like neighborhoods and especially workplaces, regardless of socioeconomic status.[3] Meanwhile, exposure through the workplace is exacerbated by the fact that many Black Americans do not hold remote access jobs. Preexisting health disparities, the result of disadvantaged access to basic healthcare and diagnoses patterns, are compounded by high employment in essential jobs which increase the risk of infection and community transmission.

The result is a feed-forward loop: structural inequity leads to disproportionate representation in low-paying jobs, simultaneously reinforces unequal rates of COVID infection, and increases community spread and risk of death. As seen in early hotspots, this cocktail of dangerous circumstances not only increases the likelihood of infection, but also of susceptibility to infection. It is an exploitative system that affects all essential workers, but, as evidenced by COVID-19 infection and death rates, none more harshly than Black workers.

It is no surprise that in many states, Black patients exhibit higher diagnosis rates and fatalities due to COVID. As Black patients are turned away from hospitals and testing sites, or resist seeking them out altogether for fear of being refused care, a culture of blame has sprung up faulting Black Americans for their own response to the pandemic. Yet Black Americans recognized something that the rest of the country perhaps did not: the social contexts which rendered them more vulnerable to COVID. Reporting higher rates of stress, household insecurity, and, as always, low wages, Black frontline workers saw yet another facet of systemic inequality playing out in their communities. And when Black individuals and their allies of all races make the choice to protest amidst a pandemic, they identify racism as the root disease, what epidemiologists call the fundamental cause, of social and physical unhealth, including COVID infection, illness, and death. As the country continues to face this pandemic, it is vital that sociocultural explanations—like the lived experience of entrenched anti-Black racism in the workplace, the home, and the doctor’s office—be considered in conjunction with infection rates. It is not enough that COVID has opened the door to increased visibility of racial health inequity: going forward, this visibility must be analyzed and paired with relevant context and active legislation.

Analysis of the Families First Coronavirus Response Act and the subsequent Heroes Act, meant to guarantee paid sick leave for COVID cases (as recommended by the CDC), indicates that 40% of workers are still falling through the gaps. Many of these workers are low-wage, female, and people of color. Meanwhile, in direct response to the COVID crisis, the CDC has undertaken to monitor racial data on the virus, but has not decreed collection of this data mandatory. Neither has the CDC itself found that the federal government should take further steps to mitigate the specifically racial public health crisis. Instead, more and more public figures have called for data on COVID’s racialized impact. At the forefront, Senators Elizabeth Warren, Kamala Harris, and Cory Booker have made public demands for released data. Harris rolled out her COVID-19 Racial and Ethnic Disparities Task Force Bill, which would create a national task force to review data and direct financial assistance.

What the current crisis offers employers and legislators is the chance to draw connections between race, job quality, and health. Steps as simple as necessitating paid sick leave and tax-exempt hazard pay can help workers now. Specific to the service industry, personal protective gear must be federally mandated, and priority given to worker safety above customers who have the option to shelter in place. As the Brookings Institute argues, doing so requires federally defined, regionally specific databases of frontline positions in order to determine who will receive benefits. Doing so would also clearly outline the contributions the service industry, and its racial demographics, have provided to the nation at large.

Looking into the future, it should be clear to legislators that an overhaul is needed. The Economic Policy Institute recently published a report that Medicare for All, which by definition would provide all residents with high quality health insurance benefits, would allow employers to redirect allocations from benefits to wages, boosting paychecks in every sector, while allowing workers to select jobs for skill sets and wages, rather than for benefits.

Further, a radical and federally-led reprioritization of customer service jobs, including acknowledgment of racial inequity, is a must. Newly created, full-time positions must promise livable wages and relevant benefits. Raising the floor on minimum wage is tantamount, but so is the concept of wage-adjusted reparations. This approach aims for more than job parity, or racial representation in any given position, but economic justice. Destigmatizing vital roles, like direct customer service, by addressing discrimination and investing in communities can break down barriers of career stagnation and current racial entrenchments in” bad” jobs. The concept of a “color-blind” but racially segregated economy is not, and has never been, defensible, especially with lives at stake.

The paradox of designated essential work is that it remains necessary to lowering overall infections, but is complicit in raising infections among its own workers. A tight focus on the racial circumstances of that paradox reveals both a deeper disparity and a way forward. Protective legislation will not pass so long as the specific experiences of Black service workers is ignored . But with an eye towards racially disparate infection rates, we also have the opportunity to address underlying economic issues that impact all workers in essential but underappreciated and unprotected jobs.




[1] Data derived from the COVID Racial Data Tracker, powered by The Atlantic. Numbers from July 27, 2020.

[2] These data and all other employment estimates come from the Center for Employment Equity's Diversity Analytics data visualization on state variation in private sector employment by occupation, race, and sex.

[3] Dorothy E. Roberts, Fatal Invention: How Science, Politics, and Big Business Re-Create Race in the Twenty-First Century. (New York: The New Press, 2011): 137.

[4] States excluded due to lack of reported data or statistically insignificant population (less than 1%)