Worker health in COVID-19 times: reflections on health, safety, and occupational therapy

Abstract

This theoretical essay aims to point out the main contributions in the health and workers' safety aspects, considering the laws, public policies, international recommendations, and point out possible paths and roles of Occupational Therapy to fight against COVID-19 Brazilian pandemic. The literature shows that health care workers have three times more likely to get infected than the general population. Thus, in Brazil, the Federal Government needs to articulate with the local and regional sphere to create, adapt, implement and inspect laws, policies, and standards on workers' health and safety to ensure conditions to work and reduce health risks for workers during the pandemic. Regarding Occupational Therapy, initial guidelines were pointed out about the work in the occupational health, considering policies of the Unified Health System, National Health Policy for Workers and Federal Council of Physiotherapy and Occupational Therapy. The actions must be directed not only to health service workers, but also to other essential assistance services, and those who work in an unregulated manner.

Keywords:
Public Health; Occupational Exposure; Occupational Health; Occupational Therapy; COVID-19; Coronavirus

Resumo

Este ensaio teórico tem o objetivo de apontar importantes contribuições, no âmbito da Saúde e da Segurança do Trabalhador, no que se refere ao enfrentamento da COVID-19, baseando-se em leis, políticas, normas e recomendações internacionais sobre o assunto. Pretende-se, ainda, identificar possíveis atuações em Terapia Ocupacional, saúde e trabalho, levando em consideração o combate à pandemia no Brasil. A literatura aponta que profissionais da saúde têm três vezes mais chances de contrair o vírus do que a população em geral. Por essa razão, no Brasil, o Governo federal precisa se articular com os estaduais e os municipais para elaborar, adaptar, implementar e fiscalizar leis, políticas e normas sobre saúde e segurança do trabalhador, de forma a garantir condições de trabalho adequadas e diminuir os riscos à saúde dos trabalhadores durante a pandemia. Sobre a Terapia Ocupacional, foram pontuados direcionamentos iniciais acerca da atuação no âmbito da saúde do trabalhador, considerando o que preconizam o Sistema Único de Saúde, a Política Nacional de Saúde do Trabalhador e da Trabalhadora e o Conselho Federal de Fisioterapia e Terapia Ocupacional. Convém enfatizar que ações não devem ser direcionadas somente aos trabalhadores dos serviços de saúde, mas também aos de outros serviços assistenciais essenciais e considerar estratégias para alcançar os que trabalham de forma desregulamentada.

Palavras-chave:
Saúde Pública; Exposição Ocupacional; Saúde do Trabalhador; Terapia Ocupacional; COVID-19; Coronavírus

1 Introduction

On March 11, 2020, the World Health Organization (WHO) declared the outbreak caused by the new coronavirus (SARS-CoV-2), a global pandemic ( Cucinotta & Vanelli, 2020 ). First detected in December 2019 in the city of Wuhan, China, this virus causes a disease called COVID-19, whose clinical status ranges from asymptomatic infections to severe respiratory conditions. In Brazil, the first case was notified on February 21, 2020 ( Gorbalenya et al., 2020 ).

Since then, several countries and institutions have been updating the disease figures almost in real-time. The website created by Johns Hopkins University and the WHO is an example of ways to disseminate this information, which releases daily reports on the evolution of the pandemic and describes the main changes of the situation of the previous day ( Candido et al., 2020 ; World Health Organization, 2020 ).

In the report No. 94 of 23 April 2020, WHO confirmed the worldwide existence of 2,544,792 cases and 175,694 deaths. These numbers quickly surpassed those of the last pandemic - the swine flu (H1N1) - which caused 18 thousand deaths worldwide, between 2009 and 2010. In Brazil, there were 43,079 confirmed cases and 2,741 deaths caused by COVID- 19 in April, placing it as the country with most cases in South America. The number of deaths in the country by COVID-19 doubles every five days and exceeds the rates in Europe and the United States (Cândido et al., 2020; Pierre, 2020 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ; World Health Organization, 2020 ).

The almost continent called Brazil - due to its vast territory - with its cultural diversity, the uneven economic distribution, and the great variability of its health equipment has challenges for the effectiveness of surveillance in the area of Occupational Health. The reduction of investments and the constant process of the precariousness of the Unified Health System (SUS), mainly in the last three years, after the inclusion of a new tax regime within the scope of the Federal Budget and Social Security Budgets through the approval of the Constitutional Amendment 95, have been testing the organization and structure of the Brazilian surveillance and assistance system (Lacaz et al., 2019). Aspects such as the unpreparedness and lack of protection of health teams or this pandemic are important to be discussed.

SUS is considered the largest public health system in the world, even though it has been underfunded since its creation. It has been providing the necessary basis to cope with actions for COVID-19, as it has a network of services, equipment, and human resources. However, the lack of investment, its disorganization, and its disruption are more evident in times of crisis. Thus, we can observe the insufficient number of human resources in health; the lack of training of primary care and medium complexity teams to deal with the suspicions and cases of COVID-19; the insufficient number of personal protective equipment (PPE); the lack of professionals specialized in emergency services; the few internal prevention actions in the care spaces, among other actions necessary to face emergency public health situations ( Romero & Delduque, 2017 ; Lacaz et al., 2019 ; The Lancet, 2020 ).

The discussions on the normative production needs that involve the health and safety of workers, when facing public health emergencies - Aedes aegypti, H1N1, zika virus - and the health legislation regarding disease control need to be updated. Therefore, the Brazilian State must ensure health and safety during the execution of its productive activities to comply with the National Health Policy for Workers (PNSTT) ( Romero & Delduque, 2017 ; Brasil, 2018 ; Lacaz et al., 2019 ).

To cope with the COVID-19 pandemic, Brazilian states have promoted individual and collective actions to deal with health and economic impacts. On April 2, 2020, governors of the states of the South and Southeast Integration Consortium (COSUD) met and proposed economic and fiscal measures that would help local governments to face the health crisis. Also, the nine states in the Northeast of Brazil created the Scientific Committee to Combat Coronavirus (C4NE) to help governors find the best way to plan the use of resources to fight the proliferation of the virus and structure the health system, associated with the adoption of measures of social isolation little-discussed under the current legislation. These measures recognize SUS workers as the greatest and most powerful force to fight the pandemic ( Romero & Delduque, 2017 ; Lacaz et al., 2019 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ).

In early April, the Federal Government, through Ordinance No. 639, which has the strategic and mandatory action 'Brasil, Conta Comigo' presents a proposal for the work of occupational therapists to combat and treat COVID-19 “[...] aimed at training and registration of health professionals, including physiotherapists and occupational therapists” ( Brasil, 2020c , p. 01). All regular professionals at the Federal Council of Physiotherapy and Occupational Therapy (COFFITO) and at the Regional Council of Physiotherapy and Occupational Therapy (CREFITO) need to register regarding the objective of the regulation, which aims to “[...] provide training to professionals in the Health area in the clinical protocols of the Ministry of Health for coping with COVID-19, and should last until the end of the pandemic” ( Conselho Federal de Fisioterapia e Terapia Ocupacional, 2020 , p. 1). The inclusion of the occupational therapist in the training offered by the Government of Brazil shows that he is an important and necessary professional to face the pandemic ( Brasil, 2020c ). Therefore, it is essential to discuss the possibilities of acting at this moment.

Thus, this theoretical essay aims to point out important contributions within the scope of Worker's Health and Safety to cope with COVID-19, based on laws, policies, standards, and international recommendations on the subject. We also intended to identify possible actions in occupational therapy, health, and work to fight against the pandemic in Brazil.

2 Health, Safety, Work, and Coronavirus: Possible Directions Regarding the Performance of Occupational Therapy

In both Brazil and China, the first deaths from COVID-19 were contaminated workers during the performance of their duties. In Wuhan, the first deaths were from workers in the city's seafood market, considered the initial source of contamination due to the handling of live animals. In Brazil, one of the first victims at the beginning of deaths was a domestic worker, infected after being exposed to the virus by her employers who had returned from Italy earlier in this year ( Goumenou et al., 2020 ; Leme, 2020 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ).

The high transmissibility of the virus, the lack of PPE, the work overload, and the impacts on mental health are the main challenges that health workers experience in coping with the pandemic. The National Health Commission of China reported that more than 3,300 professionals had been infected by the beginning of March. In Italy, 20% of healthcare professionals were infected after having contact with infected patients. The infection also affected cleaning service workers, and the lack of adequate PPE in hospitals was the most reason for the increase in infection rates ( Romero & Delduque, 2017 ; Leme, 2020 ; Tavares, 2020 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ; Goumenou et al., 2020 ; The Lancet, 2020 ).

The scientific literature on this theme highlights that health professionals are three times more likely to contract the virus than the general population. In Brazil, about 3.5 million workers act in the Unified Health System (SUS). In the state of Pernambuco, more than 1,353 health professionals were tested positive for COVID-19 - one of the highest contamination rates in the country ( Goumenou et al., 2020 ; Tavares, 2020 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ).

Among the 14 professional categories in the Health area who are in the front line in combating and treating the pandemic and considering what the SUS and PNSTT advocate, we understand that occupational therapy is a profession that can develop actions both with individuals who contracted the disease and their relatives and health workers, in addition to actions to prevent contagion ( Brasil, 2018 ). According to the COFFITO – Conselho Federal de Fisioterapia e Terapia Ocupacional (2020) and with ordinances of the Ministry of Health, the occupational therapists have supported to act in the areas of Primary Health Care, from the Family Health Support Centers (NASF), and the hospital network, considered important devices to fight against the pandemic. Through Resolution No. 459, of November 20, 2015, the aforementioned Council also regulates that occupational therapists are competent to work in the Occupational Health area, through programs of inclusive strategies, prevention, protection, and recovery of health.

In Primary Care, the main actions directed to the population performed by the profession are the guidelines for the prevention of contagion, to learn how the assisted people develop their hygiene daily and environment habits and how they can acquire new habits to avoid contagion and transmission of the virus that are consistent with their possibilities, their social, economic and cultural context and the conditions in which they live. Occupational therapy can also develop actions aimed at the processes of adaptation/reformulation/reorganization of activities performed in the daily lives of assisted individuals and families - both with families that can remain in social isolation and those that are in situations that some of its members need to leave the home environment to work. The matrix support of the Family Health teams with actions to welcome professionals and reorganize work processes is also essential ( Pimentel et al., 2011 ; Brasil, 2020a ).

In the hospital environment, occupational therapy can contribute to adapting patients to the hospital's routine and the daily care required; clarify about the disease and its treatment, so that the patient understands his new situation; position the patient on the bed properly and prevent pressure ulcers; create assistive technology devices and resources that enable the daily activities, such as eating, dressing and performing self-care in the hospital environment, and create, together with family members, strategies necessary to continue doing the main activities performed in family life, while one of its members is hospitalized. Actions to welcome family members due to the impacts of involuntary withdrawal between family members and grieving situations are also necessary, especially those of care provided to people in the process of becoming ill, hospitalization and imminent death, considering the biopsychosocial factors repercussions resulting from this process ( Frizzo & Corrêa, 2018 ).

In the work of health workers, occupational therapists can intervene through actions aimed at monitoring and supporting these professionals, especially in cases of absence from work, and helping them to adapt to new work routines and return to work processes and also, actions that aimed at solving problems imposed by the challenges found to ensure protection and safety for the work of health professionals ( Lancman et al., 2016 ).

However, health professionals, including those who intervene in the occupational health area, face challenges when working in the pandemic, and one of the main challenges is the scarcity of PPE, a reality found in several countries. Understanding working conditions and devising strategies to prepare/train workers to develop their work activities are attitudes that must be taken urgently to decide how resources will be allocated, proposals to organize work and create protective measures that prioritize the health of workers and to face and deal with the pandemic in essential care services ( Romero & Delduque, 2017 ; Brasil, 2018 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ).

The insufficiency of this equipment is only one of the aspects observed in the process of devaluation and degradation of health work. Research, publications and several reports from professionals in the area who describe the hard and long working hours; physical and mental exhaustion; the lack of assistance from managers and the Brazilian governmental system; and the lack of essential equipment and devices for the diagnosis and treatment of individuals with suspicious clinical conditions or contaminated by the virus (rapid tests, respirators, oxygen balloons, among others). These aspects are also combined with the anxieties to make difficult decisions at the time of screening, with the pain of losing co-workers and patients, with the risk of infection for them and their family members and the inability to do rapid testing on a large scale due to the lack of vaccine and treatments with scientifically proven efficacy ( Brasil, 2018 ; Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ; Cucinotta & Vanelli, 2020 ; Candido et al., 2020 ).

3 Precarious Work, Unemployment, and Worker Health: Emergency Actions in the Pandemics

In Brazil, the devaluation and precariousness of the work of health professionals are historic. This work is characterized by low wages, lack of a career plan, weakened employment relationships, high workloads, and insufficient continuing education actions targeting workers ( Romero & Delduque, 2017 ; Porto & Martins, 2019 ).

The pandemic caused by COVID-19 shows the fragility of laws and regulations that ensure the health and safety of workers. Although protection measures, training and the provision of adequate working conditions for professionals in health establishments are necessary, it is very important to obtain more resources for these measures, hiring a greater number of professionals on the front line, reflections and actions that focus on the organization of work processes, approximation of management responsible for work environments, qualification/training of workers, among other actions.

From 2019, the current government of Brazil made several changes to the rules that regulate safety at work. The changes were supported by businessmen, but much criticism was attributed by the unions and the Public Ministry of Labor (MPT) ( Warth, 2020 ). The government says that the change in safety standards aimed at reducing demands made on companies have more profitability results for them. In terms of regulations that guarantee the safety of workers, the Brazilian government has been going backward in the previous labor achievements.

In this perspective, as the pandemic spreads, the need to use PPE and to adopt awareness, training and protection measures, is not only important for the health professionals, but also for workers who act in other public and private services considered essential in times of a pandemic, such as cleaning, security, food, sale and distribution of medicines, sale of fuels, funeral services, and others.

Although it is not the central objective of this paper to deepen into the issue of the health and safety of workers involved in other essential services other than health services, training, regulations, and interventions on safety at work should cover all workers. In Italy, supermarket cashiers reported that they received disinfectant gel, gloves, and only a mask, which should be reused ( Goumenou et al., 2020 ). In São Paulo, the Public Ministry of Labor (MPT) registered about 500 complaints against companies that exposed their employees to the risk of contamination, registered between March 1 and 24, 2020 ( Rede Brasil Atual, 2020 ).

Regarding the well-known under-reporting of the number of people with COVID-19, mainly in the Brazilian reality, occupational groups have not made a specific notification, so it is not possible to evaluate where and under what circumstances the individuals tested positive or diagnosed with the disease were working, nor to identify sources of dissemination related to work activities ( Fiho et al., 2020 ).

The social isolation of the population and the use of PPE to circulate are two of the main measures to be adopted to increase the protection of everyone and, in particular, of workers who have guaranteed the continuity of the life of society in general ( Comitê Científico de Combate ao Coronavírus do Consórcio Nordeste, 2020 ). At this time, the Brazilian State must ensure social protection for the entire working class, including those facing problems with deregulation since in February this year, the rate of 41.1% of informal workers was reached, one of largest in the country's history ( Almeida, 2020 ).

Considering that, in some countries of the world, there is a high rate of workers who have formal employment bonds protected by rights and social protection, the measures adopted to combat the pandemic will be more efficient. This is because the protection proposed by the Government will take place within already consolidated provisions. However, in the case of developing countries, which have high levels of social inequality and many workers in the informal economy or unemployed, the effects of the virus will be more devastating, especially in health workers. Consequently, the Government and the frontline professionals must dedicate to elaborate measures against the pandemic, which, in general, will have more difficulty in having the desired effect ( Melo, 2020 ).

Regarding the informal workers, we should point out that professionals who develop actions that consider the impacts of work on the lives of subjects need to reflect on the development of health education actions that can extrapolate the formalized health network and reach individuals in situations atypical working conditions. From the moment a pandemic is installed, workers in essential services that face a shortage of labor rights may be subject to receiving less training and information to perform their work safely.

Regarding the guarantee of a basic income for individuals unable to work, financially harmed by the pandemic or who face different financial difficulties, in Brazil, Bill No. 873 of 2020 was approved to provide an income emergency aid in the period of coping with the crisis caused by the pandemic for R$ 600.00, for up to two people from the same family - in this case, a total of R$ 1,200.00, for three months, for individuals registered in the Bolsa Família Program and the Cadastro Único , to informal workers, individual microentrepreneurs (MEI), self-employed and unemployed ( Brasil, 2020b ).

It is necessary to ensure the implementation of the principles and actions advocated by the National Policy for Workers' Health and other labor policies and legislation, as well as to create, reformulate and implement effective measures in the area of occupational health and safety for workers of all services considered essential in Brazil. Among other challenging and unprecedented aspects posed by the pandemic, we highlight the high viral load and its fast transmissibility, which require fast and efficient management and decision-making mechanisms to guarantee protection, good quality of life, and more dignified working conditions for all frontline workers. Also, the establishment of a basic income is extremely necessary for populations facing high unemployment rates and a high incidence of the informal economy.

4 Final Considerations

The pandemic updates the defense of SUS and its principles of universality, integrality, and equity, as well as the systems of guaranteeing the rights of the Brazilian working class: the right to access health services; social protection, in cases of impossibility to perform their work activities; decent, instrumentalized and protected work for health workers and essential public and private services; basic income, in case of unemployment or unregulated work; and, more than ever, the fundamental right to life.

As this is a theoretical and reflective essay written amid a pandemic, emergencies related to laws, rules, and guidelines on safety at work and professional actions need to be constantly reviewed. Based on this reflection, expanded discussions should be held on the limits and possibilities of practicing occupational therapy in the health area, specifically in the fight against pandemics, and to systematize the experiences that have already been made.

In this scenario of a health emergency, occupational therapists have been proposing practices for the prevention of contagion and/or health problems arising from COVID-19 within the scope of Primary Care. Also, the health promotion and recovery such as the reorganization of family life in the diversity of new contexts. In the hospital environment, actions of postural adequacy to guidance to family members of people hospitalized by COVID-19. And in the scope of worker health, care practices with frontline workers and reorganization of the work processes of these teams, as well as their permanence and return to work after contagion. Occupational therapy has a wide scope of action in these three areas and that in the Occupational Health area, its actions may cover all workers in the areas considered essential, based on the understanding of their working conditions, considering the role of the State, labor legislation, recommendations of the International Labor Organization and the need for interinstitutional and intersectoral interventions.

In this sense, in the fields of practice and research, occupational therapists should be based on the interventions that will be carried out in the sphere of occupational health, during this period, describe their experiences and contribute to the scientific reference on the theme, contributing to publicize and disseminate the importance of the profession for the health of workers and in the fight against coronavirus.

• Como citar:Barroso, B. I. L., Souza, M. B. C. A., Bregalda Como citar: Barroso, B. I. L., Souza, M. B. C. A., Bregalda, M. M., Lancman, S., & Costa, V. B. B. (2020). Worker health in COVID-19 times: reflections on health, safety, and occupational therapy. Cadernos Brasileiros de Terapia Ocupacional. Ahead of Print.https://doi.org/10.4322/2526-8910.ctoARF2091

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Publication Dates

• Publication in this collection
  21 Sept 2020
• Date of issue
  Jul-Sep 2020

History

• Received
  28 Apr 2020
• Reviewed
  17 June 2020
• Accepted
  05 Aug 2020