Abstract
BACKGROUND:
The arrival of COVID-19 in Brazil and the accelerated process of dissemination/contamination added to the evolution of the clinical picture of the disease, and the saturation of the capacity of health services, creating new challenges for researchers, governments, and professionals involved in the occupational health area.
OBJECTIVE:
This article aims to systematize and synthesize the proposals adopted by the legislation and by the Brazilian State, with a focus on worker protection and guaranteeing a safe work environment for the performance of their professional activities.
METHODS:
This is qualitative bibliographical research of the narrative literature review type, developed from October 2020 to June 2021 in legislation databases using the strategy: “COVID-19” AND “coronavirus/coronavirus” AND “worker health” on official Brazilian government websites.
RESULTS:
The lack of an emergency plan for efficient actions to respond to the epidemic caused and is still causing the daily deaths of workers.
CONCLUSION:
There is a need to guarantee the effectiveness of national and international policies and norms that have been neglected by the Brazilian government.
Introduction
In March 2020, the World Health Organization (WHO) declared a global pandemic status due to severe acute respiratory syndrome caused by the new coronavirus (SARS-CoV-2). In Brazil, the firstnotification took place in February 2020, with the first victim being a female domestic worker, infected by her employers during work activity [1–4].
In Brazil, from January 2020 to January 2023, there were already 36.423,138 confirmed cases and 694,411 deaths caused by COVID-19 [4]. Underreporting of this data should also be considered due to the scarcity of tests in the public health network and the lack of access to health services in remote areas. The number of deaths from COVID-19 doubled every five days and exceeded the rates of Europe and the United States in terms of the speed and lethality of the contagion [1–5].
It is important to emphasize that the weaknesses of the health service system in Brazil are linked to the neoliberal policy model, which privatizes and imposes a health system financed only for some social classes. The privatization program, which deregulates the state, has been taking place since the 1970s in Latin America, more strongly in 1990 in Brazil, with the adoption of a series of measures aimed at reducing state spending, such as the privatization of public sectors, abandoning the Brazilian population, and subsidizing the Unified Health System in Brazil, which is public and guarantees access to all Brazilians and foreign residents. In this context, the areas of governmental health in the public spheres, through the neoliberal model, are weakened and subjected to market logic, in which the State is the sponsor of health. In this case, the provision of social well-being for the population is transferred to civil society [1–5].
During the pandemic, the reflection of these social inequalities, inherent in the health model of the neoliberal system, was observed, and how these became evident to health professionals, who in most establishments did not have basic support for professional practice, as well as much of the population.
The epidemiological bulletins issued by the WHO, the Ministry of Health, Municipal and State Health Departments, and the Scientific Committee to Combat Coronavirus of the Northeast Consortium (C4) establish a relationship between the numbers of infected people and beds occupied in hospitals, transforming our view of the pandemic [1–3].
Even if the existence of health systems is analyzed in terms of the number of physical beds, equipment, and supplies, the driving and vulnerable force that drives the equipment, receives patients, improves protocols, and accommodates the pain of those who remain after the death of loved ones is human in nature – the workers. Social workers, nurses, physical therapists, physicians, occupational therapists, and various technical workers and assistants, along with countless other professionals in administration, cleaning, and logistics, promote the functioning and effectiveness of the health system [6].
The physical and mental illness of Brazilian workers goes beyond the health crisis of COVID-19 and is directly related to the social and political crisis faced in recent years and accentuated by the global health crisis [1, 5].
In the first year of the COVID-19 pandemic, the global prevalence of anxiety and depression increased by 25%, according to a scientific summary released by the WHO [4].
The Federal Council of Medicine (CFM) recognized through Opinion 04/2020, that in order to face COVID-19, sufficient and adequate staff are needed; individual and collective protective equipment (PPE and EPC); sufficient hospital and Intensive Care Unit (ICU) beds, with good quality facilities and with an adequate quantity of equipment, medicines, and consumables; early referral to intensive care, when indicated; appropriate preparation of Health professionals for adequate mechanical ventilation strategies, following the recommendations of the Clinical Management Protocol for the New Coronavirus [7].
Other advice from health professionals also made recommendations about the protocol, including care with safety at work, as well as the release of calls, teleconsultations, and other safety measures. The Council of Physiotherapy and Occupational Therapy (COFFITO), through Resolution no. 516/2020, refers to face-to-face consultations, teleconsultations, teleconsulting, and telemonitoring, providing guidance on the use of PPE and the working hours of front-line professionals [8].
The Federal Council of Psychology (CRP), through Resolution no. 04/2020, regulated the provision of psychological services during the pandemic state, through information and communication technology [10]. The Federal Nursing Council (COFEN), due to the serious health crisis occurring in the country, authorized nursing care through teleconsultation, in addition to guiding the actions to be carried out by Nursing professionals through Resolution no. 634 [10].
These recommendations were not sufficient, nor did they find direct resonance in daily work. As a result, we observed a high rate of contamination and lethality among health professionals. Working in the health area brings professionals closer to patients infected with SARS-CoV-2, which raises infection levels among workers and contributes to the spread of the virus [10].
The United States estimates that frontline healthcare workers may account for 10–20% of all COVID-19 positive diagnoses [11, 12]. In the U.S., contamination of healthcare workers is a work-related illness [12].
In Italy, in March 2020, the number of infected professionals exceeded 6,400 [13, 18], while in China, the lethality surpassed the mark of more than 5,000 cases in 2020, with more than 1,700 health workers, most of them in the province of Hubei [7, 8] infected by COVID-19, six of whom died of viral pneumonia.
In Brazil, the data on contaminated health professionals indicates that about 240,000 workers tested positive for COVID-19, with the most affected being nursing technicians and assistants (34.5%), nurses (15%), and doctors (11%). Community health agents and unit receptionists are also in this ranking [13–16].
Health workers are being more directly affected by the current public health crisis in multiple ways, as contamination is associated with a lack of design to protect workers’ health, caused by the scarcity of PPE, lack of organizational measures, long working hours causing fatigue, suffering, and physical and psychological violence [16, 19]. Added to this are the economic crisis, social distancing, uncertainty about the future, and concern for family members [1, 20–22].
Health workers are at least three times more likely to be infected during their professional practice than the general population [11]. Quantitative research has also shown that professionals who treat patients with COVID-19 are more at risk of having mental health problems [20–22, 24–26].
The rapidly evolving epidemic, and the risks to the health and safety of health workers, associated with the neoliberal economic model, revealed a scenario already familiar to Brazilians, in which the negligence of public policies, especially the underfunding of the Unified Health System (SUS), further disrupted the health system, causing an even greater overload, also affecting the science carried out at Universities and Federal Public Institutes, as well as the devaluation of work and workers, especially those in public services [23].
Concerning social and, consequently, family distancing, workers are still concerned about infecting their family members, which results in even greater distancing, generating stress, insomnia, anxiety, and other symptoms related to fear of infection. In Hubei, China, health professionals were allocated to the city’s hotel network as a way of reducing contagion among their families [24–26].
In Brazil, workers who have better socioeconomic conditions have left their homes and isolated themselves from their own families, and when they stay in hotels, they pay for the accommodation. In some isolated situations, municipalities have made it possible to pay for the accommodation of professionals [27, 28]. For example, a private hospital in São Paulo agreed to a special contract with a hotel chain to serve doctors and nurses who live more than ten kilometers from work or who live with people in the risk group. The Municipality of João Pessoa agreed with hotel companies to provide at least 50 rooms for professionals who needed to stay away from their homes [27, 28].
In general, the framework of precarious work evolves strategically in favor of the neoliberal system and the privatization of health systems, creating new situations of risk and uncertainty that would need to be adequately managed, to legitimize the decisive role of public health workers in the effectiveness and guarantee of their own lives and the lives of the national population [1, 29].
Still concerning the Brazilian context, little is discussed about organization and working conditions, and after two years of the pandemic, protocols with recommendations for individual measures (hygiene and use of PPE) have prevailed, provided for in the protocol for clinical management of coronavirus, focused exclusively on biosafety and fundamentals, but insufficient to control the spread and exposure to the virus [17, 26]. Even for health professionals directly involved in patient care, little is discussed about the time of exposure to the virus, routine, work organization, and mental coping strategies. Measures at the institutional level are individualized and come mainly from state governments and private companies [21, 29].
In this sense, this article aims to summarize the proposals adopted by the legislation and the Brazilian State, with a focus on worker protection. It also intends to reflect on how these measures can guarantee a safe work environment for the performance of professional activities.
Methodology
The empirical material that is presented is the result of qualitative bibliographic research of the narrative literature review type, developed from October 2020 to June 2021. The option for the narrative review considered the need to systematize and summarize the proposals adopted by the legislation and by the Brazilian State with a focus on worker protection. Since this phenomenon is recent and emerging, there has been a restriction on state legal publications, maintaining our scope to federal laws and norms.
In operational terms, the research was designed in two stages. The first stage corresponded to a theoretical practice based on selecting and filtering regulations relating to the area of Occupational Health. During this stage of reading and collecting the findings, a guide was created to analyze the existing and new laws and their relationship with the National Policy on Occupational Health (PNSTT), presented below.
In the second stage, subjects researched and found by the researchers were divided, in which social protection and legal protection for workers were listed as relevant subjects for this study.
The search for scientific publications was carried out in three federal legislation databases, available for online consultation: websites of the Chamber of Deputies; the Federal Senate, and the Federal Government Legislation Portal; for international research involving guidelines, the website of the International Labor Organization (ILO) was consulted.
The following descriptors in Portuguese were used: “COVID-19” AND “coronavirus/coronavirus” AND “worker health”. The inclusion criteria were as follows: the lower should be indexed in the database, with full availability of integral forms of the text; they have been published within the research time window – 2020 to June 2021; and deal with matters involving health and safety during work.
For Grant and Booth [30], qualitative studies involve the empirical and progressive systematization of knowledge to understand the group internal logic.
Results and discussion
Research carried out in Brazil with a diverse population of health workers [1] revealed serious aspects in relation to work during the COVID-19 pandemic. Intense damage to the mental health of those who assisted infected patients in critical moments of the pandemic, especially during the first (April and May 2020) and second waves (November and December 2020). When it comes to the most commonly reported changes in the daily lives of workers, they were: sleep disturbance (15.8%), irritability/frequent crying/disorders in general (13.6%), inability to relax/stress (11.7%), difficulty concentrating or slow thinking (9.2%), loss of career or life satisfaction/sadness/apathy (9.1%), negative feelings about the future/negative thinking, suicidal thoughts (8.3%), and in appetite/weight change (8.1%) [19].
When it comes to the prevalence of anxiety and depression among frontline professionals, the indicators are higher than for health professionals who did not work on the frontline. Also, nurses presented higher rates of anxiety, insomnia, and depression than doctors, dentists, and other frontline professionals [19, 22].
The fear of being infected and contaminating family members has been reported in several studies, in addition to low self-confidence, low occupational safety, and high hours/workloads, as vital risk factors that need to be considered in the design and implementation of future psychological support services for health professionals who have experienced this pandemic and those who may experience other future ones [19, 22].
In addition, the lack of Personal Protective Equipment (PPE) was reported in studies that describe the high increase in demand for PPE in several hospitals, increasing the possibility of risk of infection for health professionals [1, 20–22].
The WHO suggests the use of traditional masks for workers who carry out routine activities in the health system, while for those who are in contact with infected patients, the guidance is: masks with respirators, faceshild, lab coat, gloves and disposable gowns. Although they highlight the importance of the precautionary principle, these recommendations, in Brazil found it difficult to be fulfilled, mainly in the Unified Health System, due to the availability of these PPE, due to the overbilling of the companies and the high import fees [1, 20–22].
The discomfort caused by the PPE was reported in several studies, the most common discomfort was related to the constant use of the surgical mask, which caused marks on the face, itching, dehydration and a feeling of anguish [8, 20–22].
Social protection is a worker’s right
The Brazilian Constitution of 1988 (CF/88) establishes, in art. 1, the existence of five fundamentals of the Republic, in particular, human dignity (item III) and the social values of work and free enterprise (item IV). Likewise, art. 6 presents the list of constitutionally treated social rights: “education, health, food, work, housing, transportation, leisure, security, social security, protection of motherhood and childhood, assistance to the destitute” [31].
The existence of a multiplicity of constitutionally contemplated rights and the lack of a formal hierarchy among such rights require the use of the weighting technique to analyze, according to the specific case, which of the constitutional values should prevail, remembering that life, health, safety, and assistance to the destitute should be given priority at all times [32].
Brazilian legislation is extensive but flawed in the context of the pandemic, despite including recommendations from international bodies on actions to combat COVID-19. However, regarding the maintenance and/or resumption of economic activity, it conflicts with the workers’ right to health, and the State had to create mechanisms to reconcile the two constitutional rights, in which it must always privilege the worker and maintain life and human dignity [31–34].
If the Constitution guarantees the right to work, it simultaneously defends the existence of mechanisms for “reducing the risks inherent to work, through health, hygiene and safety standards”, as provided for in art. 7, XXII, the maintenance of economic activity must be recognized as a defense mechanism for workers and their income. On the other hand, it guarantees that nothing can override the right to life, security, and assistance and that it is necessary to guarantee this right, which, in the current case, would imply more protective mechanisms than just PPE. Gaps such as the lack of inspection of safety and health measures at work need to be addressed [29, 32–36].
It is noted that, despite the human experience pointing to the individual aspects of the disease, there is a need to verify it from a collective perspective, based especially on solidarity and the feeling of belonging to the whole [5, 34]. From this point of view, economic activity cannot be abruptly stopped because of reduced income and the need to maintain and supply the market with goods and services. For this, the State needs to mitigate the impacts caused by the pandemic and make work possible, in a dignified and safe way, in addition to ensuring income and social protection for all Brazilians [21, 34–39].
According to the ILO, about half of the world’s economically active population was at risk of losing their livelihoods during the second half of 2020 and throughout 2021 in countries that will not control the pandemic, including Brazil [4, 35–39](Table 1).
National laws and what they advocate
National laws and what they advocate
The process of devaluation of human work, inequality, privatization of health, the precariousness of work, organization of production relations, and new forms of intermittent employment contracts weaken the health, economy, and welfare systems in Brazil and point to the neoliberal dynamics of worker exploitation, causing suffering and illness to workers, in addition to COVID-19 [1, 40].
In the specific case of present-day professionals in the Health area, their work is characterized by low salaries, lack of a career plan, positions and salary, weakening of labor ties, associated with multiple working hours, and insufficiency of permanent education actions aimed at the workers themselves, in addition to a more organized worker health surveillance system [1, 25].
In addition to the “new” Brazilian national policy, since 2016, the federal government has been making several modifications to labor laws and standards [1, 40]. These changes were supported by demands from the agricultural sector and by the large national and international industries installed in the country, starting from the point that the neoliberal system is based “on the primacy of the market, on competition, on minimal state intervention and the private sector efficiency” (p. 5) [39].
Due to the chaos experienced by front-line workers in facing the pandemic, it is necessary to increase the number of health professionals hired and put into practice actions that focus on the organization of work processes that include the approach of the management responsible for work environments, qualification/training of workers, among other actions [1].
From this perspective, ensuring access to quality health care and decent work could be optimized through reallocations of public and party funds to combat SARS-Cov-2, increasing the common fund and the Health budget, in general, protecting and expanding the coverage of social and health protection mechanisms during and after the pandemic [41, 42].
Transfers of income via existing or new programs, adapting legal conditions, and ensuring the proper functioning of humanitarian cash transfer mechanisms complement and strengthen the national social protection system. This goes beyond the understanding of the obligation to protect workers in the informal economy, through the adoption of innovative policies to reach, transfer and transition to the formal economy in the long term [1, 42].
From this perspective, it is necessary to implement the principles and actions recommended by international documents on worker protection, as a new way of reorganizing the working classes [1, 44].
The feeling of security and preparedness to deal with the health crisis are essential elements to maintain the work and well-being of health professionals and administrative sectors working to combat the pandemic.
In the context of COVID-19, multiple sectors, services, and agencies were responsible for collaborating with health professionals to ensure their protection. In this scenario, it is necessary to give special attention to the Union, the Judiciary, and the Public Ministry of Labor (MPT), which, despite their efforts, have not been able to fully protect the health and lives of workers who are working on the front line in the fight against COVID-19.
In the case of the Union, especially through Laws 13,979/2020, 13,982/2020, 14,020/2020, and 14,040/2020, which make working hours more flexible; institute telework; guarantee emergency aid for some workers; implement mandatory compliance with health measures for work, and establish the abbreviation of undergraduate courses in priority areas such as health and the creation of incentives to act in the fight against COVID-19, through the “O Brasil Conta Comigo” (Brazil Counts on Me) strategy, by example. All measures, besides reducing the impacts caused by the pandemic, indicate a necessary and mandatory “concern” on the part of the Legislative and Executive departments towards work and the right to health. It is important to highlight that such measures were not sufficient and do not corroborate the State’s commitment to the Brazilian population, established by the 1988 Constitution [31].
For several researchers, when dealing with the supply of PPE, at the current conjuncture it represents “sending soldiers to a war without ammunition” (p. 272). The lack of parity of weapons in the fight against COVID-19 is established if professionals do not have minimum aspects of protection, which results in occupational illness [41, 43–46].
It is not typical of the pandemic, but the health crisis amplified the evident communicative difficulty between federated entities (Union, State, Municipalities, and Federal District) and constituted Powers. The limitation of collective bargaining caused by the weakening of unions after the implementation of Law N°. 13,467/2017, the so-called “Labor Reform” that disfigures the Consolidation of Labor Laws (CLT) [44], associated with the lack of protection and slowness of representative class entities, brings to the fore the individual interests of a small portion of the working population - entrepreneurs and the neoliberal system [5, 25].
This pandemic confirmed the weakening and failure of union bodies but, at the same time, their importance and necessity. In the Health area, unions and class councils mediated important issues about the safety of medical and nursing workers. The Minas Gerais Physicians Union has prepared a guide on conduct and necessary conditions for medical care for patients with confirmed symptoms of, COVID-19 [43].
COFEN in the state of São Paulo was one of the first to issue guidelines for workers to act in the face of the new coronavirus pandemic, ensuring professional practice, in line with ethical and legal principles [10].
Due to the lethargy of unions and class councils, professionals in the health area were left unprotected by the lack of a project aimed at serological screening based on expanded symptomatology; granting emergency aid; more flexible working hours; more flexible sick leave and sick leave policies consistent with public health guidelines, as well as emergency hiring of new professionals [1, 46].
It is also important to pay attention to the diversity of the country, not only because of its territorial expansion, but so that any legislation or action is equitable. Rethinking the principles of universalization, equity, integrality, decentralization, and popular participation, already advocated by the SUS, can be a coherent way to face the crisis, with regard to concerning the protection of workers, as well as “to strengthening the bond with people and understanding their situation within a ‘living territory’, through their family configuration and the community in which they live” [1, 46].
Focusing on the humanization of work can also be a way to guarantee individual and collective protection in the field of work, considering psychological support for health professionals43, the concept of advocacy among nurses [45], or the articulation of the Psychosocial Care Center in the territory, are some clues of actions already carried out, which can be fostered for the protection of workers [1, 46].
Conclusion
Work and working, organizers of life in society, have given way to abrupt changes in our society, such as individual and collective changes in behavior, in the way of working and behaving in public spaces; private life habits; routine changes; mobility; social engagement and consumption patterns, which affected everyone, in addition to the biological and clinical aspects of the disease. Unemployment, social helplessness, reproduction of poverty, and threats to workers’ rights have driven the continuation of a conservative neoliberal project that touches on labor rights.
An emergency plan with actions to respond to the epidemic should have been prioritized in the Brazilian State, guaranteeing the health and safety of workers at different levels of healthcare. It has become urgent and challenging to protect the lives of these frontline workers and, consequently, of the entire Brazilian society. Therefore, it is necessary to implement national and international policies and norms to guarantee the health and safety of workers, including the strengthening of the PNSTT and other labor policies and legislation.
The impacts caused by the COVID-19 pandemic on the physical and mental health of healthcare professionals have been extremely worrying, especially for those who are directly linked to coping with the pandemic, as they are a group that is very vulnerable to the psychological and emotional impacts resulting from their work environment and the conditions linked to the pandemic.
This article, with the objective of systematizing and summarizing the proposals adopted by the legislation and the Brazilian State, aims to protect the worker, and guarantee a safe work environment. During a pandemic, emergency situations related to laws, norms, and guidelines related to the subject, as well as professional performances, need to be constantly reviewed, due to the speed with which norms and laws adopted in times of pandemic are changed.
Nevertheless, as this is a narrative review of the literature, this research should be evaluated with caution, as this review may have limitations regarding the types of laws selected, since the research was limited to Brazilian law, given the chaos and public health emergency faced in Brazil during the first two years of the Covid-19 pandemic. In order to improve the quality of future publications and reduce the risk of possible biases, the authors suggest further reviews with the inclusion of a systematic review with meta-analyses, as a way of presenting the gaps in the law and standards that make it difficult to provide comprehensive care for workers in their work environment.
Footnotes
Acknowledgments
The authors carried out this work in name of all workers who died during the COVID-19 pandemic.
Ethical Approval
Not applicable.
Informed Consent
Not applicable.
Conflict of Interest
None to report.
Funding
None to report.
Author contributions
Bárbara Iansã de Lima Barroso: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing - original draft, writing - review & editing, supervision and project administration.
Carla Aparecida Alves da Silva: investigation, resources, data curation, writing - original draft, writing – review and editing.
Igor de Lucena Mascarenhas: investigation, resources, data curation, writing - original draft, writing - review and editing.
Lilian de Fatima Zanoni Nogueira: conceptualization, investigation, resources, data curation, writing - original draft, writing - review and editing.
Wellington Batista Ferreira: conceptualization, investigation, resources, data curation, writing - original draft, writing – review and editing.
Angélica Barros Araújo: investigation, resources, data curation, writing - original draft, writing - review and editing.
Ana Cristina de Oliveira e Silva: investigation, resources, data curation, writing - original draft, writing- review & editing.