The US healthcare system depends on the labor of immigrant healthcare professionals, a fact mainly unrecognized and unreported during the pandemic. Twenty-eight percent of physicians are foreign-born, as are 22 percent of nursing assistants (Batalova 2020). The immigrant professionals make up even more of the workforce in healthcare positions that are undervalued, in comparison to what is considered skilled medical care, such as providing personal care to elderly adults, a population particularly vulnerable to COVID. Thirty-eight percent of home health aides nationwide are foreign-born, with even higher proportions in states that were hit hard by the first wave of the pandemic, like New York and New Jersey, where 75 percent and 55 percent of home health aides, respectively, are immigrants (Batalova 2020). We have heard horrific stories about hospitals and long-term care facilities, with hospital workers in particular praised as “heroes,” but less from the workers of long-term care facilities or their colleagues who work even more invisibly in home care. Such representations overlook the ways that key sectors of the US economy rely on immigrant labor, whether in healthcare or meatpacking (Miraftab 2016), and the ways that the pandemic might disproportionately affect immigrants.
Elder care serves as a niche employment field for African immigrants in the United States. One home health worker described coming to the United States in 1995 from Ghana, and explained that “this nursing—nursing assistance job was the only job you could do quick.” Speed was important because many in the home country were awaiting the migrant’s financial support. Newly arrived immigrants learned from more established immigrants within their networks that they should give up their dreams of continuing in their previous profession and take up elder care work instead, whether in a nursing home or home care, after a short course of several weeks. Because of the high demand for elder care, nursing assistance promises continuing employment. Elder care pays somewhat better than retail and fast-food service, particularly if one works more than forty hours a week, through multiple jobs at multiple sites.
Because of COVID’s threat to older adults and residents in congregate settings, it affected elder care workers in many ways. Nationally, 80 percent of deaths from COVID were among adults sixty-five years or older (Freed et al 2020). There have been numerous outbreaks in congregate settings like long-term care facilities, with which at least 40 percent of all COVID-related deaths in the United States have been associated (there is evidence that this figure is probably an undercount), (Chidambaram, Garfield and Neuman 2020). Healthcare workers are more likely to be infected, but their risk of death from COVID is similar to the rest of the population, affected by age and other conditions, although it is worth noting that statistics about rates of infection among healthcare workers are not always collected and are thus not very accurate (Hughes et al 2020).
Five years ago (2014-2016), I did research with home health workers in New Jersey and in the Washington DC metropolitan area, which I published as The New American Servitude: Political Belonging among African Immigrant Caregivers (New York University Press, 2019). The book’s argument was that conditions of work in home care generated a sense in African immigrant caregivers that they did not belong politically in the United States. What they pointed to directly was the racism and lack of respect they encountered from their patients and the lack of appreciation as represented in the conditions of work, including low pay, lack of benefits, and the precarity in employment. The Affordable Care Act expanded health insurance to this group of low-income workers, but did not cover all of them, revealing the promises and pitfalls of this program. Home care workers could lose a job suddenly when a patient went to the hospital or complained about them. The lack of care that they received made them feel unwelcome in the United States, as a place where their care was not reciprocated. The research was based on 59 care workers, with half from Ghana. Most of the others from elsewhere in West Africa, with a handful from East Africa; all but nine were women. I also talked to 25 patients or their families who used home care, and 16 staff from home care agencies.
Between August and October 2020, I followed up with these care workers, speaking to 21 of them through phone or Zoom. I had kept in touch with five of them over the years, but with most, I was speaking with them for the first time in five years. The interviews were retrospective, looking back at a pandemic peak in April and May, during a lull. This timing felt ethical, as interviewing them during a peak when they were exhausted would have made them only more so. Although New Jersey experienced more of an outbreak in the spring than Maryland did, in both states, COVID intensified the hardship of care work.
Home Care is Back! Changes in the Preferred Work Setting
During my previous research, home care workers compared the pay and benefits they received from working through an agency to employment at long-term care facilities. Hospitals served as the gold standard of employment, but were out of reach for this group of workers. Facilities were preferred to home care because of employment stability and retirement and health benefits to nursing assistants, while agencies were seen as the most exploitative, paying workers half of what families paid them, and offering precarious work that could end at any time. Most of those I had met worked in a variety of settings simultaneously, in order to compensate for the low pay by working many hours and to cushion the blow when a job ended suddenly, due to a patient’s death, hospitalization, lack of finances, or desire to let them go. Turnover and working multiple jobs are common in elder care, setting conditions by which a virus can spread rapidly.
Those I talked to in 2020 had very different experiences of COVID’s impact based on where they were working. There were three main contexts in which my research participants worked. One setting was in a patient’s private residence, whether a single-family home or an apartment in a non-age-restricted apartment building, working as a home care worker hired by an agency. The second was working in a long-term care facility, whether a nursing home unit or an assisted or independent living wing, as an employee of that facility. The third was working in a long-term care facility, but as a home care worker hired independently by an individual resident through an agency or personal connections. This use of both facility resources and an additional caregiver from an agency was a fairly common practice among patients before the pandemic: a family might want the extra care and individual attention that a home care worker would provide in a nursing home, to supplement the care of the staff; or someone living in independent living in a long-term care facility might hire a home care worker to prevent having to move into the more stigmatized and expensive assisted living wing.
Across these three settings, research participants reported several similarities in their work during the pandemic. One, they could not socially distance from their patients. Patients needed lifting, feeding, and bathing, all of which brought caregivers and patients into close contact. Those with dementia did not keep their distance and did not understand what was happening, so they reached out for hugs from their caregivers or pulled down their masks, despite yelled warnings.
Care workers also all reported working harder, whether because of safety precautions, the loneliness of the patient, or having to do more because of shortages of other workers. Care workers in the facilities were now required to take vital signs every shift, or change gowns between patients.One care worker in an assisted living facility described how she spent more time lifting her residents’ spirits because they could not receive visitors; another said that the residents were more confused and more depressed because they could not go outside or receive visitors; and a home care worker talked about how she and her patient were becoming best friends, because there was nothing for them to do but talk to one another. A home care worker working with a resident of a facility described how housekeeping staff employed by the facility no longer came into the apartment to clean because of fears of infection, so she now had the additional burden of keeping the apartment neat and tidy.
Some care workers took a few weeks off during the height of the pandemic, because they were afraid of the disease or they needed to organize childcare. Because of COVID, some stopped working multiple jobs, although others did not. Only one among the 21 research participants stopped working in elder care, because she had given birth in December 2019, after many years of miscarriages, and wanted to be sure to protect the baby she had been longing for.
The Safety of Home Care: “Nothing Changed”
There is some evidence that older people and their families preferred home care to long-term care facilities, because of the increased sense of risk due to the number of outbreaks and deaths there, particularly in New Jersey. Some patients and their families had no choice in the matter: they were transferred from the hospital to a nursing home for rehabilitation, or could not afford home care. But those who could choose the location of their care, chose care in their own home. The six home care workers whom I interviewed had no trouble finding work during the pandemic. One who had been searching for work for a long time, because of her inability to drive, finally found the live-in job “of her dreams,” she told me, with a generous family.
Home care workers also felt safe doing home care, working “one on one,” as they called it. However, only rarely was it actually one on one, since a co-worker came in on a different shift to relieve them. Some live-in workers protected themselves and their patients by staying longer in the patient’s home, when normally they might go home for a short visit every two months or so. One stayed seven months with her patient, from the end of November to June.
They reported that their patients were more fearful and anxious, perhaps because of isolation or fears of mortality. One reported that a patient, with whom she previously had a positive relationship, became more suspicious: the caregiver faced accusations of stealing whenever she went out of sight of the patient, and the patient’s daughter questioned the caregiver about her habits because she was concerned about her bringing the virus into the house. Her relationship with this family felt less warm and close as a result of tensions due to COVID.
It was among these home care workers that I heard that nothing much had changed due to COVID, although when I probed, there had indeed been changes, as noted above. Home care work had become more valued by workers and patients alike for its perceived safety. One home care worker said that working in the facilities was “terrible.” And indeed, the experiences of workers in long-term care facilities were much more traumatic. They were eager to speak to me, and they had a lot to share.
“So Many Residents Died”: Fears and Traumas in the Long-term Care Facilities
The eight caregivers who were employed by the long-term care facilities all spoke of death.
A lot of people died. The staff didn’t die, but many staff caught it. So many staff caught it. So many residents died. Some were affected [by COVID] and it still lingers. They have pneumonia, after being tested for COVID, and then just died. They are not linking it to COVID, but in retrospect, COVID has something to do with it. A staff member, her husband died. She had it, but she was asymptomatic. She took it home, and her husband died.
Another caregiver said that among her 15-bed memory care unit (for dementia patients), four staff members caught COVID and almost all the residents had it, with a third of them dying.
The deaths of residents were traumatic on the care workers. One said, “Some nights, two to three people died. The dying itself and the sickness, I can’t describe it.” Another said that those who died were so sweet and nice, and you remembered the time that you spent with them, but you could only mourn on the first day, because you were so busy and there were new deaths every day. The residents who died have not been replaced, because of family and patient fears about congregate living, so the bed count (as it is called) remains low. Some employees of long-term care facilities were worried about the financial viability of the institution. Some lost employment hours because of the low bed count.
The deaths of residents and the sicknesses of co-workers were frightening. One care worker said that she would see a co-worker test positive and ask herself, What did they not do? She said, “I see the person so cautious. If they could get it, I could get it. They were washing hands; they have the mask and shield on for 12+ hours. Every day, someone got it.” She also described the atmosphere, “It’s tense. The residents are tense.” This is similar to what Freidus and Shenk (2020) reported, from a study of care work in a long-term care facility in North Carolina, in which caregivers worked in an atmosphere of fear.
Staffing shortages made things worse. Co-workers (but not my research participants) were hesitant to work because they feared getting sick, had trouble with childcare, or were quarantining. One employee of a long-term care facility said that older workers or those with a health issue resigned from the facility, and she did not blame them for it. “People are scared,” one said. The facilities could not find new staff to replace them, because caregivers preferred to work in home care and “one-on-one” instead. As a result, sometimes, employees were working more hours. One care worker got sick after working a double shift she hated (first night shift and then morning shift), because of staffing shortages, and which she thought contributed to her getting COVID. She was running a fever soon afterwards and had to help a co-worker pick a resident who had fallen off the floor because of the staff shortages, before she left to quarantine and recover at home. The lifted resident caught COVID, which she attributes to her caring action.
Those who worked in long-term care facilities reported a lack of personal protective equipment and disinfectant at first, in March and April. Some used the same gown over and over again, meaning that the re-used gown passed close to the face as it was pulled on, or even wore a trash bag. One said, “At the initial stage, we run out of masks, gowns, even sanitizer.” But by August and September, they were all well-equipped. Wearing PPE for many hours was stressful and very hot. One caregiver reported,
At the end of the shift, it’s like, you breathing but something is missing. All these masks, all this protective gear, it decreases your mind, your brain. . . . One of the staff was about to snap because someone was late [and so the staff member could not go home at the end of the shift]. [I told her,] “Please be patient.”
She said, “No, I need to get out of the mask, I need to breathe.”
I said, “You don’t know why she is late.” After that, you become a therapist now, without pay.
But she also understood her co-worker’s frustration. As she said, “You looking forward to that time [of getting off work], and someone is calling out. Then you have to stay by law.”
Those in the long-term care facilities were being tested regularly, generally every week. Testing allowed them to catch infections early, so that the risk of outbreaks declined over the summer. Some complained that the testing was brutal; some caregivers experienced nose bleeds or their eyes watered for some time afterward, making it difficult to go straight to work.
Losing Work: Providing Home Care in a Long-term Care Facility
The seven care workers who were hired privately by residents of long-term care facilities were the most likely to report unemployment or underemployment and to express anger about the lack of care demonstrated by their agencies. Facilities were concerned that private duty caregivers hired independently by residents were bringing in the virus, and so there were constraints on their movement in and out of the facility. One of my research participants was suspended from entering a long-term care facility, losing her job as a result. Another could only work in one facility, but not others, to prevent the spread of the virus between facilities. Some live-in workers had trouble getting groceries for themselves into the facility. As a result, this category of workers lost more work than the other two.
Some home care workers in the facilities considered facility residents to be safer than patients living alone in their own homes, because they were tested regularly, whereas those in their own homes were not. It was the home care workers in the facilities, not those in individual residences, who noticed and were angry about how little they were protected by their agency, because they were able to compare their protections to those employed by the facility. They noted their lack of PPE and COVID tests, in comparison to the facility workers. The long-term care facilities took care of their own workers, but not employees of an outside home care agency, and the agency’s protections were not as comprehensive as the long-term care facilities. States had stepped forward to help prevent outbreaks in long-term care facilities, but generally ignored home care agencies, even though home care workers were working in those same facilities.
All the care workers I interviewed protected themselves through means other than PPE. Nearly everyone talked about drinking a kind of tea, although each had his or her own special recipe, adding different ingredients to the hot water. They sometimes called it “herbs” or “vitamins,” but always marked it explicitly as an “African practice.” Used for malaria prevention and treatment in their home countries, this tea was repurposed to combat COVID. As an example, one home care worker said,
I have been scared, and what we have been using to protect ourselves in Africa, we do a lot of traditional medicines. We use hibiscus flowers, for tea, and put cloves, black pepper, ginger, lemon, and pineapple. We boil it, and sieve it out. You drink a cup when you go out, and when you come in. My country [Ghana] used this for the COVID, and we have done well. We [Ghana] have been open for three months [that is, out of lockdown].
The one care worker I interviewed who got sick and recovered from COVID credited a similar concoction with her recovery. When she returned to the facility, she learned many of her co-workers used it to protect themselves prophylactically and berated them for “not sharing” it with her until she got sick. She now shares this recipe with everyone. Protective recipes are communicated through social networks, both inside and outside of workplaces, transnationally through diasporic communities.
Care workers also increased their religious activity, mainly in a personal dimension, through prayers or more informal group phone calls organized around prayers, since they could not attend religious services. Some had more time to pray with family members, because everyone was at home rather than running around to school and work.
There was widespread refusal to take any hypothetical COVID vaccine, even if their employer mandated it. A variety of reasons were mentioned: fears of live virus, difficult experiences with other vaccines, concerns about the vaccine being used to kill Black people specifically, and a general lack of trust in the Trump administration.
The care workers reported that their relatives in their home countries were more concerned about them and called frequently during the pandemic. They expressed pride in how their home countries in Africa dealt with the virus, whereas the United States was brought low by it. Like public health and infectious disease experts (Agbanyim 2020), they had a wide range of somewhat speculative explanations for why this happened, mentioning sunlight and a warmer climate, exercise, government public safety measures, and the use of hibiscus tea.
In my book, I noted how bitter home care workers were about their conditions of work and how they were treated by agency staff and their patients. Yet they did not participate in the “Fight for $15” minimum wage campaign, unionization efforts by domestic worker organizations, or domestic workers’ labor legislation, all very active efforts at the time of my original research (Boris and Klein 2010). Home care workers in New York City, including many Caribbean and Southeast Asian home care workers, had pressured the New York Legislature to pass the Domestic Workers’ Bill of Rights in 2010 (Glaser 2015). African care workers certainly recognized the injustice of their working conditions. Denied reciprocities to which they felt entitled through their good care of others, they asked to be recognized as human beings and deserving of care. However, as Lois McNay (2008), drawing on the work of Susan Gal (2003), notes, “There is a huge difference between recognizing injustice, identifying systemic domination and common interests, devising strategies for action and, finally, feeling able to act. Even when there is substantial misrecognition and subordination, resistance might not emerge if the symbolic elements with which to formulate agency are not present” (140). I thought COVID might have provided language for discursive claims or symbolic expression, to enable African immigrant care workers to be less fractured in their private pain and find common ground to mobilize. Given the simmering resentments, did the hardships described above due to COVID boil over into overt or organized political action?
I continued to hear anger and frustration at the lack of care exhibited by agency staff and facilities and about the disrespect from patients. Some of this, such as frustration over the lack of PPE or increased confusion or anxiety among patients, was related to COVID, but some was a continuation of concerns about disrespect and precarity which pre-dated the pandemic. I did not hear new symbolic claims arising from being “essential workers,” or healthcare workers protecting the nation’s health or its elderly. Generally, it did not feel as though care workers’ anger was being channeled into political action. On the other hand, I also did not hear an increased interest in “exit” (or return migration) due to the pandemic (see Hirschman 1970). I found this somewhat surprising because the risk from the pandemic was generally lower in my research participants’ home countries, but perhaps it was because they considered the long flight to be an exposure risk.
In general, the care workers talked about growing habituated to the new conditions. As one said, “In the beginning, I was very, very scared. Now, not much.” They were less afraid in late summer and early fall than they had been during the spring peak, and they were committed to seeing the pandemic through, hopeful that there would be a change in the future to something brighter.
The pandemic has illuminated the existing weaknesses of the US healthcare system. Often ignored in that healthcare system is the long-term care of chronic conditions. The workers who perform that care are also undervalued, leading to turnover and long working hours in multiple jobs. Neither those who receive such care nor those who provide such care are well-served by a system that does not reward experience and skill or nurture close relations. Like other healthcare workers during the pandemic, African immigrant elder care workers mobilized in response, adapting to the pandemic’s intensification of their work. Despite their bitterness about the ways that care work is not valued, both before and during the pandemic, my research participants seem unlikely to mobilize to generate systemic changes in elder care and elder care work. Instead, they share recipes of protection and engage in individualized strategies in response to their fears. Their recalibrations may augur the pandemic’s long-term effects: it may highlight the problems in the US healthcare system more clearly, without leading to broader changes, because the onus will be placed on individualized protective behaviors, rather than create a more equitable, and more caring, new normal.
Africans comprised 11.7% of direct-care workers in the United States in 2003-2009, with the numbers doubling from 2005 to 2015 (Campbell 2018; Martin et al 2009); the countries best represented were Nigeria, Ghana, Liberia, Kenya, and Ethiopia. Thirty-nine percent of Africans working in health care were nursing, psychiatric or home health aides (McCabe 2012). However, in some cities like Washington D.C. and New York City, the foreign-born share of care workers was much higher (Martin et al 2009), and has increased since 2009. Agencies I interviewed in the Washington metropolitan area and northern New Jersey in 2013-2016 reported that their workforce was 60-80 percent African.
Cati Coe is a professor of anthropology at Rutgers University, and the author of The New American Servitude: Political Belonging among African Immigrant Home Care Workers (NYU Press, 2019).
Agbanyim, Oluchi. 2020. “COVID-19: A Closer Look at Emerging Trends in Africa.” SSRC. https://kujenga-amani.ssrc.org/2020/11/12/covid-19-a-closer-look-at-emerging-trends-in-africa/
Batalova, Jeanne. 2020. “Immigrant Health-Care Workers in the United States.” Migration Policy Institute. https://www.migrationpolicy.org/article/immigrant-health-care-workers-united-states-2018
Boris, Eileen and Jennifer Klein. 2010. “Making Home Care: Law and Social Policy in the U.S. Welfare State.” In Intimate Labors: Cultures, Technologies, and the Politics of Care. Edited by Boris and Rhacel Salazar Parreñas, pp. 187-203. Stanford: Stanford University Press.
Chidambaram, Priya, Rachel Garfield, and Tricia Newman. 2020. “COVID-19 has Claimed the Lives of 100,000 Long-Term Care Residents and Staff.” Kaiser Family Foundation. https://www.kff.org/policy-watch/covid-19-has-claimed-the-lives-of-100000-long-term-care-residents-and-staff/
Coe, Cati. 2019. The New American Servitude: Political Belonging among African Immigrant Home Care Workers. New York: New York University Press.
Campbell, Stephen. 2018. “Racial Disparities in the Direct Care Workforce: Spotlight on Black/African American Workers.” Research brief. New York: PHI.
Freed, Meredith, Juliette Cubanski, Tricia Neuman, Jennifer Klates, and Josh Michaud. “What Share of People who had Died of COVID-19 are 65 and Older?—And How Does It Vary by State?” Kaiser Family Foundation https://www.kff.org/coronavirus-covid-19/issue-brief/what-share-of-people-who-have-died-of-covid-19-are-65-and-older-and-how-does-it-vary-by-state/
Freidus, Andrea and Dena Shenk. 2020. “‘It Spread Like a Wildfire’: Analyzing Affect in the Narratives of Nursing Home Staff during a COVID-19 Outbreak.” Anthropology and Aging41(2). Forthcoming.
Glaser, Alana Lee. 2015. “A New Day for Domestic Workers? New York City’s Multicultural Domestic Workers’ Labor and Activism amid the Introduction of Labor Law.” Ph.D. dissertation, Northwestern University.
Hirschman, Albert O. 1970. Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States. Cambridge: Harvard University Press.
Hughes, Michelle M., Matthew R. Groenewold, Sarah E. Lessem et al. 2020 “Update: Characteristics of Health Care Personnel with COVID-19 — United States, February 12–July 16, 2020.” Morbidity and Mortality Weekly Report69:1364–1368. DOI: http://dx.doi.org/10.15585/mmwr.mm6938a3
Martin, Susan, B. Lindsay Lowell, Elzbieta M. Gozdziak et al. 2009. “The Role of Migrant Care Workers in Aging Societies: Report on Research Findings in the United States.“ Institute for the Study of International Migration, Walsh School of Foreign Service, Georgetown University.
McCabe, Kristen. 2012. “Foreign-Born Health Care Workers in the United States,” https://www.migrationpolicy.org/article/foreign-born-health-care-workers-united-states#5
McNay, Lois. 2008. Against Recognition. Malden, MA: Polity Press.
Miraftab, Faranak. 2016. Global Heartland: Displaced Labor, Transnational Lives and Local Placemaking. Bloomington: Indiana University Press.
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