We know what can make us vulnerable to COVID-19 — old age, unwashed hands, underlying conditions. But as much of the country sheltered in place, a new risk factor emerged: work.
"This has become a worker-safety epidemic," said Dr. David Michaels, an epidemiologist and professor of environmental and occupational health at the Milken School of Public Health. Michaels was the head of the Occupational Safety and Health Administration during the Obama administration.
From nursing home staff members and farmworkers to bus drivers and meatpackers, the jobs deemed "essential" during the coronavirus pandemic are disproportionately held by women, immigrants and people of color, according to a report by the Center for Economic and Policy Research, a Washington, D.C., think tank.
Among the greatest divides may be between those who can work remotely and those who can't. Only about a quarter of U.S. workers can do so easily, research shows. Many essential workers work low-wage jobs that don't offer paid sick leave, making them likelier to work even while ill.
NBC News spoke to economists, epidemiologists, occupational health experts and workers across the country to understand what jobs pose the greatest risks.
Health care workers were at the top — not just doctors and nurses, but also low-paid nursing home workers, who often lack sick leave and health insurance. There are grocery store clerks and bus drivers, who regularly interact with the public but have little ability to stay home when they get sick. Also dangerous are workplaces where employees can't practice social distancing, like the prisons and meatpacking plants that emerged as COVID-19 hot spots. The pandemic has shown that the nature of one's job affects not only a worker's health but also the health of whole communities.
"This is not just about worker safety. It's about public safety," said Dr. Hye Jin Rho, an economist at the Center for Economic and Policy Research.
The certified nursing assistants
Dorothy Allen arrived at work at East Lake Arbor, a nursing home in Decatur, Georgia, the first week in May to find that COVID-19 had spread. Last Friday, there had been four confirmed cases. By the end of Monday, May 4, there were 29.
"We need help," Allen said.
Certified nursing assistants like Allen bathe, feed and tend to the elderly and the infirm in nursing homes. To get them in and out of bed, they embrace them and lift. Contact that close means that when illness enters a nursing home, it spreads fast.
"We're literally like an incubator for the virus," said one of Allen's colleagues, who asked to remain anonymous for fear of retaliation. "I'm worried for myself, my staff, my family."
They have reason to worry. To date, at least a quarter of the 76,000 deaths nationwide are tied to long-term care facilities, NBC News has found. That has strained a workforce that was already overworked and underpaid. Nearly 85 percent of staff members in the facilities are women. Just short of half are non-white, and nearly a third live near the poverty line. They often lack both health insurance and paid sick leave, and many work at multiple facilities to make ends meet.
Nursing facilities have also faced crucial shortages of personal protective equipment, or PPE. As of April 27, OSHA had received more than 310 complaints about staff exposure to COVID-19 in nursing homes, according to an NBC News analysis. That's second only to complaints from hospitals, where the shortage of protective equipment has grabbed national headlines.
"They're still begging for PPE," said Lori Porter, co-founder of the National Association of Health Care Assistants. "Nursing homes are the last to get anything, which leaves clinicians and nursing assistants very unprotected on the front lines."
Allen said she and her co-workers have pleaded with the owners of East Lake Arbor for more protective equipment. The company, Care Network, didn't respond to several calls from NBC News.
Last week, Allen said, she helped a co-worker suit up before entering the room of a resident positive for COVID-19. He pulled cloth pillowcases onto his feet and a plastic garbage bag onto his head and walked in, hoping for the best.
The transit workers
Jermaine Foreman will tell you not everyone can drive a bus in New York City. "You have to have patience and prayer," said the longtime bus operator.
That's been particularly true as the coronavirus pandemic has hit the city's Metropolitan Transit Authority workers hard. Almost 100 of the workers who keep the city's buses and subways running have died from the virus.
MTA authorities initially barred the workers from wearing masks, a move they later blamed on guidance from the Centers for Disease Control and Prevention. The agency has since taken steps to protect its 55,000 employees. Riders board Foreman's bus through the back door. He wears a mask, and his seat is wiped down at the end of each route.
"It can be scary at times," Foreman said. "It's kind of lifesaving, too. You know people are depending on you."
New Orleans, Boston, Seattle and Chicago have also lost transit workers to the virus. More than half of all bus and urban transit workers are people of color, census data show.
In Detroit, bus driver Jason Hargrove's Facebook video about a coughing passenger went viral. Eleven days later, Hargrove was the first Detroit driver to die from COVID-19. Since then, at least 20 others have tested positive, said Glenn Tolbert, president of Amalgamated Transit Union Local 26, which represents drivers in Detroit. He said all but two of his 500 members are non-white, as are most of their riders.
"The supermarket workers and the postal workers and the restaurant workers, we're taking them to work," said Tolbert, who recently recovered from COVID-19. "There's nobody checking temperatures when they get on the bus. We're putting ourselves at risk, but we understand that it's necessary for us to do our job."
Luisa Gonzalez climbs the bus steps to go to work every day as a janitor at Northwestern Memorial Hospital in downtown Chicago. Gonzalez, 66, has worked at the hospital for nearly 20 years, emptying trash cans, disinfecting floors and tidying rooms between patients.
Gonzalez is among thousands of people who work in hospitals and health care facilities who aren't medical staff, but they are exposed to some of the same hazards every day. They make up about a sixth of hospital employees in Chicago, according to a 2018 study. In New York City, more than 30 non-medical hospital employees have died.
Non-medical staff members said they were among the last to get masks when protective equipment was in short supply. They may also be the last to be told how to protect themselves, which patients are sick, what rooms to be more careful in. "Nobody gives us all the information when something happens," Gonzalez said.
A spokesperson for the hospital said it has provided protective equipment throughout the pandemic. He added that the hospital screens employees for symptoms daily, provides additional pay and is "proud of the exceptional work happening every day."
Gonzalez, a cancer survivor who is diabetic, said she wears masks and gloves religiously on the bus, at work and on her way home. She strips off her clothes when she walks in the door and cleans her phone and keys with alcohol.
"I follow all the rules," Gonzalez said. Staying home isn't an option for her or her co-workers, she said. "If we don't come to work, nobody pays us. The government sent us $1,200, but it's not enough."
"And they need us, too," she said of her hospital. "If we don't come to work, who is going to do the job?"
Hard work was part of Saul Sanchez's culture, his daughter Beatriz Rangel said. That's why her father kept clocking in to his job as a meatpacker at the JBS plant in Greeley, Colorado, even after his 78th birthday. He had worked there for more than 30 years. Last month, he was among six workers at the plant to die of COVID-19 — the highest number in any of the nation's meat and poultry facilities, the CDC reported.
Like many of the nation's plants, the Greeley facility is powered by immigrants. Over 80 percent of the workers who do the hard, messy job of butchering, processing and packaging meat in the U.S. are black or Latino, data show. More than half of them are immigrants, as opposed to just 17 percent of all U.S. workers.
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The facilities have proven to be breeding grounds for the coronavirus. Employees work elbow to elbow in sealed-off sections of the plant on lines that move swiftly, gloved hands touching the same pieces of meat one after another. Social distancing is nearly impossible.
Nearly 5,000 workers have tested positive for COVID-19, temporarily shuttering several facilities, including the JBS facility in Greeley, which recently reopened. Last week, President Donald Trump issued an executive order to keep them open to protect the food chain.
The order overlooks a key fact, said Kim Cordova, president of United Food and Commercial Workers Local 7 in Colorado. "The critical part to the food supply chain is the worker," she said.
JBS said that it is screening all employees in Greeley for fevers as they come to work and that it is providing testing for those who have symptoms. "The health and safety of our team members is our number one priority," a spokesperson told NBC News in an email. "We are doing our best to safely provide food to the country during a challenging time."
Cordova said JBS isn't doing enough. The company still hasn't tested all workers, and she said it needs to retrain employees on how to work safely in the age of COVID-19.
"They signed up for a job to work for a company and to make ends meet," Cordova said. "These workers didn't sign up to die."
The emergency responders
At the peak of New York City's pandemic, sirens wailed throughout the city. Ambulances fielded more than 6,500 calls. It felt like nearly every one was a suspected COVID-19 case, said Anthony Almojera, a paramedic with the Fire Department of New York.
At one point, about half of the 4,200-person EMS workforce was out sick. At least four workers have died from COVID-19, according to the FDNY.
"Then we see our co-workers dropping, and the fear is real. You take it home," said Almojera, who is vice president of the FDNY's Emergency Medical Services Officers Union Local 3621.
More than half of New York City's EMS workers and paramedics are non-white, and about a quarter are women. They are the lowest-paid among the city's first responders. They make about $50,000 base pay after five years, according to the city. Some have second jobs. Turnover is high.
That financial stress can add to what is already punishing work, Almojera said, particularly in a pandemic, when many are choosing to isolate from their families to keep them safe.
"I have members who sleep in their cars because they don't want to go home," Almojera said. The FDNY told NBC News that the city has had a 25 percent increase in workers seeking help through its counseling unit in recent weeks.
The separation took a toll on FDNY Rescue Paramedic Joshua Rodriguez. At the height of the epidemic, he couldn't spend time with friends and family to talk about what he was seeing on COVID-19-related calls.
"It's a lot of alone time when I get home," he said. Rodriguez wanted to keep his mind off things, so he did what he knows best. He picked up more shifts.
Farmworkers "live check to check," Armando Elenes, secretary-treasurer of the United Farm Workers, told NBC News. "They don't have the safety net that others do. And it can't be done from home."They can't digitally pick an apple."
Occupational health experts worry about farmworkers because of not only the job but also the conditions. Workers often live in communal housing, sit close on vans and buses to get to the fields and have limited access to health care. Half are undocumented, according to union estimates, making them ineligible for unemployment or stimulus programs. Many others are in the U.S. on temporary work visas and may feel less able to speak up or demand time off if they get sick, experts said.
That could threaten not just individual workers but also the country's food chain.
"These punishing policies push people into the shadows," said Suzanne Teran, associate director of the Labor Occupational Health Program at the University of California, Berkeley. "That's not going to get the country back on its feet."
The corrections officers
Nowhere in the country may the virus be spreading faster than behind bars. Last week, more than 1,200 staff members and prisoners at a Tennessee prison came up positive. More than half of the prisoners in a California facility tested positive, with at least 10 staff members infected. In Ohio, more than 2,000 prisoners and 175 staff members at the Marion Correctional Institution have contracted COVID-19.
As difficult as it might be to practice social distancing in a prison, it's particularly hard in facilities as overcrowded as Ohio's, said Christopher Mabe, statewide president of the Ohio Civil Service Employees Association, which represents corrections officers.
"You have 2,000 inmates in a facility built for 1,500. Where do you put them?" Mabe asked. "We can't just transfer them all and infect other institutions."
While the majority of the country's correctional officers are white, the spread through correctional facilities may still have a disproportionate racial impact. Black Americans, who make up about 13 percent of the U.S. population, comprise nearly 25 percent of the nation's corrections officers.
In New York City, where about 1,000 officers have tested positive, nearly 90 percent of uniformed officers in the city's Correction Department are non-white, and 40 percent are women, according to 2017 statistics. A spokesperson for the city's jails said that masks are now mandated for staff and detainees in all public areas and that common spaces are cleaned and sanitized daily.
The virus has taken a particularly heavy toll on black Americans, who have died at disproportionately high rates in at least 17 states, initial data show. Experts worry that the jobs people hold mean the racial and economic inequality will only grow as the country reopens.
"Those who can't work from home include more low-income workers, more women and more people of color," said Dr. Marissa Baker, an assistant professor of environmental and occupational health sciences at the University of Washington's School of Public Health. "We're just creating more of a divide in our society."
CORRECTION (May 7, 2020 7:30 p.m. ET): An earlier version of two graphics miscalculated the size of the circles representing the number of workers in certain front-line jobs. The sizes of the circles have been fixed.