Will COVID-19 finally force us to address the devaluation of long-term care workers?

There’s little doubt that Canada is experiencing a crisis in long-term care (LTC). This crisis has its roots in decades of under-funding and creeping privatization, but, like so many other social inequalities, has been exacerbated by the COVID-19 pandemic. As of February 2021, more than 70 per cent of all deaths attributed to COVID-19 in Canada have been traced to LTC institutions, the highest proportion of any country in the Organization for Economic Co-operation and Development.

Policy-makers, media and advocacy groups have understandably highlighted the severe negative impacts of COVID-19 for Canada’s frail and elderly LTC residents and their families.

But the pandemic has also proved detrimental for the workers within these institutions, whose problems  have received far less public attention. These workers provide essential but undervalued care and do low-wage work that is considered 3D: dirty, difficult and, especially during a pandemic, increasingly dangerous.

Anecdotally and from qualitative data, we know that racialized and immigrant women in Canada are over-represented in low-wage work within LTC. As well, data show that these workers make less than their counterparts working within hospital settings.

However, our new analysis of 2016 census data provides the first representative snapshot of the deep stratification within LTC in terms of who is employed as licensed practical nurses and nurse aides, orderlies and patient service associates (whom we term “care workers”) within nursing and residential care facilities across Canada. It also quantifies the financial penalties these workers experience and the toll that these jobs take on their physical and mental well-being.

The census data demonstrate that LTC care workers face multiple, intersecting inequalities (Figure 1). Across Canada, they are overwhelmingly women (at 90.3 per cent). Immigrant and racialized populations are substantively over-represented (46 per cent over-represented in the former case, and 65 per cent over-represented in the latter case, among the total employed, non-Indigenous population aged 18-70).

When we examine the female workforce only, further disparities are revealed. Care workers in LTC in Canada are disproportionally Black and Filipina women; are more likely than non-care worker women to be employed part-time (something that has been worsened by recent laws preventing care workers in many provinces from working in more than one LTC site at a time due to the pandemic); and have higher rates of self-rated “poor” physical health than non-care workers (figure 2). This latter point is hardly surprising, given the physically demanding nature of this work.

Yet care work remains low-wage work, with earnings far below the mean for women workers in Canada. In 2016, the mean annual employment income for women care workers was $32,538 compared with $39,845 for the total female workforce, and $58,789 for women working in other health-care occupations (18 per cent lower on average in the former case and 45 per cent lower in the latter).

Even when we do more complex analyses, and control (hold constant) pertinent factors including immigrant status, racialized minority status, official language proficiency and highest level of education completed, individual and family characteristics, city of residence, and employment factors (including hours worked), we continue to find a care-work wage penalty of $1,684 per year for women across Canada (meaning women care workers in LTC make $1,684 less than comparable women workers in other fields). This suggests that there is something about care – something that scholars argue is related to its continuing association with “women’s work” and to jobs historically done by women in private homes for free – that leads to a lesser market valuation of care.

When we run similar analyses, we also find that care workers have higher odds of self-rated poor physical and mental health than comparable non-care worker women, again net of immigrant status, racialized status and numerous other pertinent factors.

These data are perhaps unsurprising for those who work in the LTC sector or who have family or friends who reside there. However, they do provide concrete numbers that further demonstrate that LTC employees are especially vulnerable due to the front-line nature of their employment, as well as their gender, citizenship status, race and/or class. Thus, as we have previously noted:

At present, the most vulnerable workers provide the most essential services to the most vulnerable clients under the worst working conditions.

Yet, if we think of the pandemic as a potential turning point – a time when as a society we can start to truly care about care – there are concrete policy steps that can be taken to reduce disparities faced by LTC workers in Canada.

In the short term, these workers require fair remuneration and better employment protections. This means, in practice: paid sick leave and appropriate staffing levels; higher pay (including overtime); personal protective equipment; accommodations to reduce workplace injuries’ mental health supports; safe transportation to and from work facilities; emergency housing for self-isolation; and child care. These protective factors will help both to mitigate and to compensate for the risk of COVID-19 exposure that these LTC care workers face, as well as begin to address the burden that has been placed on their families and communities.

In the longer term, there is a need to reimagine how we fund, staff and care for vulnerable people in LTC in Canada. This must include universal and public funding of LTC (recent data from British Columbia have documented that private institutions fared worse during the pandemic); further unionization among LTC care workers; increased pay-equity measures; greater accountability; and transparency mechanisms by government and the private sector; as well as more and better data about the demographic profile (gender, race and immigrant status) and health outcomes of COVID-19-affected LTC workers.

Such changes will no doubt require both a shift in the value we ascribe to care work, as well as major reinvestment in caring infrastructure (both human and physical). But they are necessary steps if we are going to get serious about addressing our LTC crisis.