The Essential Problem: Essential Workers Category and Vaccine Roll-Outs

In November, the American Medical Association (AMA) declared, “Racism is a threat to public health.” In doing so, the AMA finally stated outright what many of us in the humanities and social sciences have been saying for decades – “the primary drivers of racial health inequality are systemic and structural racism, racism and unconscious bias within medical research and healthcare delivery have caused and continue to cause harm to marginalized communities and society as a whole.” This statement echoes the work of scholars and activists including Dorothy Roberts, Alondra Nelson, Harriet Washington, and Londa Schiebinger. The AMA policy to address racism took a step in the direction of health equality. Now we need to lean into this initiative and the decades of humanities and social science work that preceded it.

We need to lean into this because of the flexibility allowed to a term at the top of our pandemic vocabulary list: “essential.” The initial pandemic flexibility of “essential” fused together disparate sets of workers we could not do without – cashiers, postal workers, emergency room and ICU staff, nursing home personnel, healthcare professionals, warehouse staff, and police officers – into one category. Black Americans are disproportionately represented in this set of workers. Now, its flexibility is returning in another way. As vaccinations begin, “essential” is likely to shift away from the Black and low-wage communities that it entailed in the early days of the pandemic. The shift may already be happening. In this essay, we reflect on what “essential” meant during the emergence of the pandemic, how the term’s flexibility allowed for the race of “essential” workers to be hidden from view, what this invisibility might mean for Black communities who were initially “essential,” and what an anti-racist policy agenda for our collective first definition of “essential” workers during the vaccine roll out might look like.

The initial broad ranging, disparate group of “essential workers” was largely comprised of low-wage workers and overrepresented Black Americans. Some healthcare professionals were an exception to this racial generalization, as essential healthcare workers also included CNAs, hospital housekeeping staff, and hospital dining services. Using this buzzword in a flexible manner allowed our policy makers to manipulate American categorization, setting boundaries for tolerance of individual exposure. These “essential” exceptions to stay at home guidelines in the early throes of the pandemic maintained important connections in the fabric of American life like food supply chains and public safety. The flexibility of the term “essential” has enabled it to encompass a disparate set of groups, allowing for health disparities in infection rates and presenting challenges for future COVID decision-making, like who should be prioritized during the vaccine distribution process.

In the early days of the pandemic, the flexibility of the term to encompass this range of workers disproportionately exposed Black Americans to COVID and its effects. Meanwhile, as noted both by the CDC and our own article in progress on this subject, this reliance on Black American workers shielded white Americans. BLM protests over the summer of 2020 highlighted this inequity. Politicians and public health officials openly wrestled with the reality that more people of color were dying of COVID than white Americans. Some medical professionals tried to chalk this up to the disproportionate rate of pre-existing comorbidities in Black communities, without addressing the relationship between these conditions and systemic racism. By using the category “essential worker,” the relationships between professional exposure and race became obscured.

The current shift away from Black and low-wage communities in terms of who counts as “essential,” however, will deepen the systemic and structural racial divide right at a time when it could be otherwise. We witness this shift happening now: the CDC recommended healthcare workers and those in long-term assisted living facilities receive the vaccine first. Both populations do not capture many within the initial “essential” category, which is problematic in that many of those most vulnerable/exposed as essential workers do not fit in the more narrow category of healthcare worker.

An even greater problem is that current vaccination rollout plans are likely to be decided on a state-by-state basis after the first round. This would mean that each state must decide who is “essential.” Putting the definition of essential in the hands of state governments means that we can expect a confusing patchwork of rounds from US states that have a terrible historical record of racist policies. From eugenics in California and Virginia to segregation and slavery, states have found ways to consistently devalue Black American life. Perhaps more troubling is the historical nexus between racism, local institutions, and federal institutions. In Bad Blood, James H. Jones traces how the oral history of the Tuskegee experiment predisposed members of the Black population to distrust the government and public health officials when HIV/AIDS made landfall. During the 1990s, many Black Americans believed that AIDS was a form of genocide potentially made to infect Black people.^[1] This, coupled with the fact that the NIH and CDC were heading the investigation of AIDS, meant that Black Americans were supposed to believe the same institutions that had conducted the Tuskegee experiments to ameliorate this new sexually transmitted disease in their community. At the time many white Americans and medical researchers did not understand this disjunction and displaced the institutional politics of medical racism as “irrational” fears within the Black community. These “irrational” fears simultaneously erased the centuries of medical mistreatment that Black Americans had endured and the racial politics of medicine in America.

Now, as we sit on the steps of our current public health crisis, many of the same federal agencies at play have been implicated in the past racial injustices of Tuskegee and AIDS: the NIH, the NIAID, and the CDC. Their institutional histories are marked by more stories of medical racial injustice relevant to Black distrust. These include the theft of Henrietta Lacks’s cervical cells at Johns Hopkins (an institution that has been on the forefront of tracking COVID-19 and trailing COVID-19 therapies); the former AMA president J. Marion Sims using slave women to perfect a profitable surgical technique through repeated unanesthetized attempts; the labeling of BiDil as an “African American drug” after it failed to produce the desired results in white Americans; and a history of trialing inoculations and vaccinations in enslaved and Black populations.^[2] Distrust of medical institutions and the pharmaceutical industry seem appropriate. These stories have proliferated in Black communities for more than the past 40 years. In this time, many Black scholars have historically chronicled these stories for larger audiences. This has brought calls for justice, sustained distrust, and opened up medicine to racial political scrutiny.

As politicians, bureaucrats, and healthcare providers wrestle with who should get the vaccine first, we fear “essential” will shift away from those who held our semi-isolated pandemic lives together to those who can “jump start” the economic life of the country. This shift will move the vaccine away from low-wage workers toward more highly educated workers. For example, school teachers who went remote early on may become “essential” to the economic viability of the country as opposed to maintaining the “essential” characteristics of parcel delivery folks, sanitation workers, and others who worked tirelessly to keep the nation’s citizens alive in the early days of the pandemic. We encourage states to plan guidelines on vaccine roll out with members of Black communities. To prevent the move from the initial “essential” to a more capitalistic variant of “essential,” we suggest an outright recognition of the early “essential” workers and giving said individuals priority. This priority should be accompanied by free and local access to a vaccine. This, too, should be paired with true informed consent prior to vaccine administration where all individuals can consult with a healthcare provider on the vaccine, its known side effects, efficacy, and any other concerns that they may have about it.

We would like to thank Drs. Ashley Shew and Monique Dufour for their comments and suggestions on this piece.

Cora Olson

Former Elite Domestic Cyclist, Passionate Higher Education Professor working on projects around sporting bodies, inclusion and equality, and the role of empathy in medical school education.

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Claire Simpson

Claire Simpson is studying Biomedicine, Medicine & Society, and English Literature at Virginia Tech. Throughout her course of study, she has become particularly interested in the intersections of science and humanity.

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