3.8.1 Coverage of essential health services
Defining Essential Services
Broadly defined an essential service is a public good that maintains the wellbeing and development of a society. A defining characteristic of an essential service is that it is a basic service supplied to a community without interruption. National governments have the authority to determine which services should be classified as essential services. Accordingly, the United States, section 176 of the Labor Management Relations Act (1948), defines an essential service as “an entire industry or a substantial part thereof engaged in trade, commerce, transportation, transmission, or communication among the several States or with foreign nations, or engaged in the production of goods for commerce, where a strike will imperil the national health or safety, if permitted to occur or to continue”.
This definition and others used by different countries raise concerns regarding the labor rights of the workers that supply these services that individual governments decide as essential. Consequently, the designation and implementation of essential services by national governments come under the purview of the International Labor Organization (ILO). This is because the uninterrupted provision of essential services must accommodate the “fundamental right of workers to participate in the determination of their conditions of work in a meaningful way” as ratified by the ILO Convention on Freedom of Association and Protection of the Right to Organize. What this essentially means is that national-level determinations of essential services should balance national needs and the essential workers’ right to strike. ILO Member states are free to determine essential services as long as they have implemented the principles of the aforementioned ILO convention.
Yet in a working paper aimed at determining the scope of essential services the Committee of Freedom of Association (CFA) has defined the following list of essential services :
- the hospital sector
- electricity services
- water supply services
- the telephone service
- the police and the armed forces
- the fire-fighting services
- public or private prison services
- the provision of food to pupils of school age and the cleaning of schools
- air traffic control
The following table presents the state-wide status of access to essential services (broad categories defined by the CFA list above). The table is available for download here.
Another defining characteristic of essential services is that their definition is contingent on the emergency it is addressing. The COVID-19 pandemic is a good example of this characteristic of essential services. At the initial stages of the pandemic state governments determined interim definitions of essential services and workers. The table below gives an overview of the services designated by each of the three states as essential and is available for download .
Essential Public Health Services
Essential health services are aimed at improving the well-being of a community. The Centers for Disease Control and Prevention (CDC) had defined 10 essential health services to “protect and promote the health of all people in all communities” in 1994. This framework was updated in September 2020, to account for the changes in the health care needs of communities brought about by the COVID-19 pandemic.
The table below analyzes whether the state govenments of DC, MD, and VA are taking steps to comply with this framework. This table can be downloaded here.
A Poor People’s Pandemic Report
This project, conducted by the Poor People’s Campaign, aims to evaluate how COVID-19 has disproportionately impacted poor communities. Utilizing GIS mapping and local community-based data, the implications of the impact of COVID-19 shed additional light on the toll of economic insecurity, structural and systemic racism, and poverty during times of increased strain, such as a global pandemic.
The first section of the project, titled “The Unknown Toll” provides the data of the top 300 counties with both high poverty and high COVID-19 death rates. This section discusses the disproportionate number of COVID-19 deaths in the United States versus the rest of the world, specifically emphasizing the role of working in person and the data gaps that exist to showcase any correlation between job or income and COVID-19 deaths. The report lists data inconsistencies about COVID-19 fatality rates, specifically the conflicting reports of 18.2 million deaths versus 5.4 million deaths worldwide, as well as the resulting increase in persons with disabilities to one in four adults in the US alone. This section also emphasizes that while the amount of deaths are highest among non-Hispanic white people, the highest number of COVID-19 cases, hospitalizations, and resulting deaths have been higher among people of color.
The second section of this project, “The US Before the Pandemic,” discusses the pre-existing social conditions that were exacerbated by the rise of COVID-19. The project establishes the number of poor and low-income residents, as well as the number of rent burdened citizens within the United States, emphasizing the disproportionate impact on people of color. The report also provides a snapshot on Appalachia, with an emphasis on Mingo County, as one of the lowest-income counties in the United States and the related impact of COVID-19. Transitioning into the third section, “Poverty and Pandemic Outcomes,” the role of poverty rates and the impact of COVID-19 is further questioned, as the project aims to shed light on the existing data gaps about income, economic stability, and the toll of COVID-19. This section provides maps that showcase death rates, deaths by income bracket, deaths by race, and deaths by population density to emphasize the disproportionate impact of COVID-19 on people who are low-income, people of color, have less education, or are veterans. The project indicates that there are disparities in recording COVID-19 deaths of people within those identity groups.
The report uses a recent Pew study’s breakdown of six COVID-19 phases (Initial Period, Second Wave, Third Wave, Spring/Summer 21, Delta, and Omicron) to clarify COVID-19 impact over time. The deadliest phases thus far have been the winter 2020 to early 2021 or Third Wave, accounting for 40% of all deaths to date, and the Omicron phase, accounting for 20% of deaths to date. The report emphasizes how the impact of the phases varied by county specifically regarding income, as counties with the lowest median income suffered death rates twice as high than counties with the highest income for all COVID-19 phases other than the Initial Wave. By the Third Wave, death rates were 4.5 times higher in the lowest income groups and 5 times higher by the Delta Wave. Importantly, the report notes how vaccination status cannot account for the variation in death rates.
Drawing attention to the interrelated issues of racism and poverty, the report discusses the racial dimension of COVID-19 death across different phases. During the Initial Phase, Black, Hispanic, and Indigenous population suffered more deaths and more cases than the white population. While the gap begins to close by summer 2021, by the Omicron phase people of color are impacted at higher rates again likely due to higher risk of exposure with in-person work, housing, transportation, and lower access to safe child care and quality healthcare. Healthcare resource disparities also increased the risk of death particularly for Black adults. Citing a significant body of research connecting disproportionate COVID-19 deaths to racism, the report highlights how counties with more Black residents suffered significantly higher death rates. The report also touches on how life expectancy disproportionately decreased among racial and ethnic minority groups.
The report uses mapping to overlay the poorest counties with the COVID-19 death rates to reiterate their similarly. It also draws attention to the demographics of the poorest counties to demonstrate the relationship between race and poverty, especially in the southern US and uses cases from Hinds County, Mississippi and the Bronx.
The negative economic consequences of the pandemic are primarily job loss, which disproportionately affected specific members of our society—particularly low-income workers, persons of color, and women. Essential workers were also a highly vulnerable group since they had to risk daily COVID-19 exposure, yet these workers do not receive adequate compensation (less than $15/hr).
The report highlights the lack of a robust monitoring system that would allow a deeper understanding and detailed accounting of the impacts of COVID-19 across class, race, gender, age, and ability. Specific cases discussed are counties’ lack of racial breakdowns with less than 100 deaths. This omission leads to the inclusion of disaggregated data for only 34% of counties of the lowest-earning decile. Furthermore, imprecise measures such as median income and the percentage of people living below 200% of the poverty line do not consider cost of living adjustments. Finally, it is essential to consider the various approaches counties took to mitigate the impact of COVID-19 in their communities. This county-by-county approach ensures that policy evaluation and development of recovery programs consider all necessary variables.
The main takeaway from the report is that the hardest-hit communities are the ones that are poor. Some policy measures supported these communities, but they were not inadequate and needed further expansion or extension. For example, research shows that the expanded Child Tax Credit had a significant impact on reducing food insecurity and racial inequalities among poor children, yet the program expired in December 2021 and runs the risk of reversing the gains made during the height of the pandemic.
Pre-existing issues of poverty and inequality exacerbated the pandemics’ devastating effect in the U.S. The report calls for two things. Firstly, there must be a substantive and intersectoral analysis to understand poverty in relation to race, gender, age, and ability. Secondly, there must be a change in ideals to place a higher value on human life – and the country must focus on implementing initiatives and policies that support human welfare such as living wages, shared economic prosperity, access to universal and affordable healthcare, education, and essential utilities.