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Covid-19: is there a disproportionate burden on working classes in France?

A cashier works wearing a face mask in a supermarket on April 15, 2020 near Lyon. Jean-Philippe Ksiazek/AFP

While a majority of Covid-19 victims are elderly, middle-aged workers have also been affected, in particular health professionals and those holding high-contact jobs such as cashiers where the risk of exposure is high. Such front-line workers have made headlines, with demands ranging from adequate health protection measures to the cessation of non-essential activities. Those holding low-paying jobs in the essential service sectors are more likely to expose their health for economic reasons and could be suffering a disproportionate impact of the epidemic.

Recent data on Covid-19 hospitalisations indicate that the situation in France is no exception. Among those of working age, well-established patterns of workplace exposures, housing conditions and co-morbidities are likely to compound social inequalities in health in time of crisis, further to income loss and layoffs.

Nearly 40% of those hospitalised are working-age adults

Excluding cases and deaths in French nursing homes, the proportion of people aged 15 to 64 among all Covid-19 patients who have been hospitalised was 37% as of April 21, 2020, as shown below.

Patients hospitalized for Covid-19 in France, by age

Patients hospitalised for Covid-19 from March 1 to April 21. For each age group, totals comprise patients still hospitalised as of April 21, in addition to those who were either discharged or died in hospital. NED, based on Santé Publique France data

The Seine-Saint-Denis department (in the Ile-de-France region) is particularly representative of the large impact of the risks faced by working-age adults. While the department’s population is young, it ranks second among all French departments for its increase in mortality during the epidemic (+128%).

This has been attributed to the predominantly working-class composition of the department’s active population and to its level of workplace exposure to Covid-19. Prior knowledge on usual working conditions can help us understand these processes by highlighting at-risk occupations and related risks outside the work environment.

Low-paid workers highly exposed to Covid-19

Workers at risk of Covid-19 infection are those who routinely have close face-to-face contacts with the public/colleagues, and/or exposure to infectious agents. Before the lockdown, their number was estimated in France to be at least 8.8 million. There were sharp disparities across occupational groups, however. As high as 41% of the bottom quarter of earners (monthly net salary less than or equal to 1,350 euros) belonged to the highly exposed group, as opposed to 12% of the top quarter of earners (greater than or equal to 2,750 euros).

The graph below shows occupations with the highest number of salaried workers exposed to face-to-face contacts with the public during regular activities (pre-epidemic), grouped by salary quartiles.

Occupations with the highest number of salaried workers having face-to-face contacts with the public, grouped by salary quartiles

Occupations with the highest number of salaried workers having face-to-face contacts with the public, grouped by quartiles of median monthly net salary, and ordered by number of workers exposed. The survey covers 23 million of salaried workers from the private and public sectors, excluding the self-employed. Occupations such as deliverers and handlers are not shown either because their numbers are too small or because of self-employment. INED, based on French Ministry of Labour, CC BY

In addition to health care workers and first responders, whose earnings range in the middle and upper salary quartiles, front-line workers with lower pay such as cleaners, personal aids and grocery workers are among the most exposed to contacts with the public. Yet the situation of potentially highly exposed workers has changed following the lockdown that began in mid-March.

With the lockdown, changing work-related exposures

While some workers such as teachers started working from home, others face reduced hours and layoffs, including hairdressers and restaurant employees. Although their work exposures ceased, they may have been infected early in the epidemic. Those continuing to work on-site during the lockdown remained exposed to significant risks, of course.

As of the end of March, 27% of workers continued to commute to work. This proportion is likely to be higher in the essential services, where workers may also face longer hours in order to offset workforce shortages and meet exceptional needs, as in the healthcare sector.

Current exposures to Covid-19 depend on the tasks and work environment as well as the type and timing of protective measures taken by employers. In late March, at least 33% of the workers did not receive any gloves from their employer, and more than 39% had no mask. Such proportions vary greatly with workers’ bargaining power, which is weakened by job insecurity. Major drivers of the changes are shown in the figure below.

Changes in employment and working conditions since the lockdown and their impact on exposure to Covid-19

★ Transportation means not included; calculations based on the French survey on working conditions (2013) covering 26 million workers. ★★ Figures from the French Ministry of Labour survey on Covid-19 (April 2020) covering 15 million salaried workers. INED, based on French Ministry of Labour

Uncertainties around workplace risks are also bound to feed concerns about becoming infected and in turn contaminating friends and family. The virus may remain active for hours on clothes, surgical masks, the surfaces of everyday objects such as mobile phones, and of course on skin and in saliva if someone is infected.

Such exposure pathways have typically been described for chemical hazards such as asbestos and pesticides and of particular relevance regarding the community spread of the current epidemic. Take-home exposures, which include possible contamination during travel to work, have often been attributed to unsanitary worker behaviours, yet they are related to both working and housing conditions. Of special relevance are overcrowded housing and the lack of sanitary conveniences to change clothes and wash prior to family contacts.

Co-morbidities as aggravating factors

The risks related to Covid-19 infection are not only those of the disease itself. Co-morbidities such as hypertension, diabetes, obesity, severe asthma, cardio-vascular and chronic pulmonary diseases usually lead to more severe forms of Covid-19 infection and worse prognosis. Several of these co-morbidities and occupational exposure to lung toxicants are more prevalent among less advantaged social groups; moreover, lower perception of symptoms and difficulties in accessing healthcare may lead to delayed diagnosis and treatment of Covid-19 infection.

During this crisis, a neglect of the surveillance of chronic diseases may also disproportionately affect working classes, given the disruption of the health system. All the more so as France is considered to have the highest level of social inequities in health care use in Europe. Finally, early clinical observations raise the issue of long recovery after Covid-19 infection, with potential job downgrading, or, at worst, inability to resume work.

Income loss, job insecurity, longer hours

France has a social security safety net that is more protective than that of many other high-income countries – for example, when the lockdown began, measures were taken by the government to compensate for some workers’ loss of income. Yet the situation of those no longer eligible for unemployment benefits, precarious workers and the working poor could worsen, notably due to the contraction of short-term contracts. Self-employed workers, such as hairdressers and non-food retailers, may also experience significant losses of income.

This is even more the case for those working for platforms on low-paying jobs that potentially expose them to Covid-19. On the other hand, those still working among key occupations may face longer hours, intensification of work, changing relationships with managers and co-workers and work-family life imbalance. In this context, attention should be paid to a potential neglect of the usual work hazards due to a shift in priorities.

Accumulation of disadvantages

All in all, the current sanitary crisis is likely to aggravate social inequalities in health, unless more aggressive and comprehensive measures are taken to protect the population in the workplace and outside.

First, lower-salary workers are disproportionately exposed to the risk of Covid-19 infection. They are thus likely to carry a heavy health burden, especially if they are not sufficiently protected. Their risks are compounded by their transportation and housing conditions, along with their co-morbidities and limited access to healthcare. This lays the ground for greater spread and severity of the disease, both among working-age and older adults. The Seine-Saint-Denis department, where the death toll has been dramatic, exemplifies this accumulation of disadvantages.

When prevention fails, compensation is at stake. This raises other equity issues between workers, as healthcare professionals have just gained the right for compensation in case of Covid-19 infection. Lastly, residents of deprived neighbourhoods are often suspected of being disrespectful of the lockdown rules and regulations. This perception, while regularly refuted by regional health and police authorities, is yet another burden on the shoulders of working classes in France.

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