key: cord-0822428-n056ptfz
authors: Robinson, Londyn J.; Engelson, Brianna J.; Hayes, Sharonne N.
title: Who Is Caring for Health Care Workers’ Families Amid COVID-19?
date: 2021-02-23
journal: Acad Med
DOI: 10.1097/acm.0000000000004022
sha: 3226a5374e32062c5be51372da1d9e261324e15b
doc_id: 822428
cord_uid: n056ptfz

Amid the COVID-19 pandemic, women in medicine, including faculty, residents, medical students, and other health care workers (HCWs), are facing unparalleled challenges. The burdens of pandemic-associated increases in domestic and caregiving responsibilities, professional demands, health risks associated with contracting COVID-19, and the resulting psychosocial distress have exacerbated existing gender disparities at home, at work, and in academia. School and day care closures have created additional childcare needs, primarily for women, yet little support exists for parents and families. These increased childcare and domestic responsibilities have forced women HCWs, who make up the overwhelming majority of the workforce, to adapt their schedules and, in some cases, leave their jobs entirely. In this article, the authors detail how COVID-19 has exacerbated existing childcare accessibility and affordability issues as well as gender disparities. They argue that unless government and health care organization support for childcare increases, families, specifically women and children, will continue to suffer. Lack of access to affordable childcare can prevent HCWs from doing their jobs, including conducting and publishing academic scholarship. This poses incalculable risks to families, science, and society. COVID-19 should serve as a call to action to all sectors, including the government and health care organizations, to prioritize childcare provision and increase support for women HCWs, both now during the pandemic and going forward.

In this article, the authors detail how COVID-19 has exacerbated existing childcare accessibility and affordability issues as well as gender disparities. They argue that unless government and health care organization support for childcare increases, families, specifically women and children, will continue to suffer. Lack of access to affordable childcare can prevent HCWs from doing their jobs, including conducting and publishing academic scholarship. This poses incalculable risks to families, science, and society. COVID-19 should serve as a call to action to all sectors, including the government and health care organizations, to prioritize childcare provision and increase support for women HCWs, both now during the pandemic and going forward.

If the health care sector had a theme song, it would be "It's a Man's Man's Man's World" by James Brown and The Famous Flames. 1 The COVID-19 crisis has placed extraordinary burdens on all health care workers (HCWs), trainees, and their families. The goal of this article is to make a plea to expand family-centered policies for HCWs, as parents have experienced increased domestic responsibilities during COVID-19. However, both the burden on women and the exodus of women from the workforce are disproportionate compared with those for men in similar roles. 2 The unequal impact of the pandemic on women, coupled with women comprising a majority of the health care workforce, begs the question: While women are caring for patients during the COVID-19 pandemic, who is caring for them and their families?

Women worldwide spend triple the amount of time on household activities and childcare compared with men. 3 Women also frequently serve as informal, unpaid caregivers for elderly and highneed family members. 4 COVID-19 has only increased domestic and caregiving responsibilities. 5 Due to school and day care closures, parents now must juggle their children's online curriculum and playtime as well as the household cleaning, meal preparation, and grocery shopping for their home-bound families. These added responsibilities have fallen disproportionately on women's shoulders. 5 HCWs-75% of whom are women 6 have not been exempt from these added stressors. As a result, many women HCWs have been forced to make difficult decisions as they balance unrivaled childcare and domestic demands with unparalleled professional needs. 7, 8 A lack of organizational support for familycentered policies 9 has already contributed to many highly trained women HCWs leaving the workforce. 7

Even before the pandemic, many parents struggled to afford childcare, with full-time care for 1 infant costing an average of $21,700 annually. 10 This cost represents more than one-third of the average resident's salary. 11 For many essential workers, the cost of childcare actually exceeds their income. Home health aides, for example, earn about $24,200 annually, 12 far less than the cost of care for 1 child in Washington, DC, California, Seattle, and New York. 10 For many women, staying home with their children is more cost-effective than joining the health workforce.

Beyond cost, accessible day care is not available for many families. 13 Childcare deserts are common, especially in rural areas and minority communities; 3 in 5 rural communities and nearly 60% of the Hispanic/Latinx population are in areas with an inadequate number of licensed childcare centers. 13 In addition, many HCWs are forced to find alternative care options on nights and weekends because less than 8% of centerbased care providers offer childcare during nonstandard duty hours. 14 As a result, the vast majority of childcare is provided by unpaid caregivers; retired family members and friends provide approximately 50% of childcare. 15 Unfortunately, most older adults are at increased risk for developing serious COVID-19-related complications and have been advised by the Centers for Disease Control and Prevention to limit their contact with those outside their household. 16 This has forced families to make agonizing decisions between allowing grandparents to provide free childcare and finding costly alternative options. The loss of unpaid caregivers has led to an abrupt rise in childcare needs that licensed centers are not able to meet due to COVID-19 regulations. Parents and guardians have been forced to pick up the slack. 17 Fewer Childcare Options During COVID-19

The absence of childcare options before the pandemic, coupled with COVID-19related school closures, left approximately 3.45 million children of HCWs without care in the spring of 2020. 18 Lack of access to childcare during increased duty hours and school closures was listed as one of the 8 major sources of anxiety for HCWs during the first week of the pandemic. 19 Unfortunately, this lack of childcare options has led to many children of essential workers being left unsupervised while their parents work. 20 The cruel irony of the situation is that, while many HCW parents scramble to find care, most day care centers sit empty, unable to operate due to an inability to pay workers, lack of personal protective equipment (PPE), and little government support. 21 Due to COVID-19 exposure fears and an increased number of parents working from home, many children who typically attended day care have not during the pandemic. In the span of 1 week in mid-March 2020, day care centers lost nearly 70% of their daily attendance and the corresponding revenue. 22 The government encouraged day care centers to apply for relief loans via the Paycheck Protection Program sponsored by the Small Business Administration. Regrettably, only approximately 5% of childcare facilities received this funding. 17 Due to a lack of immediate financial assistance, many childcare centers closed altogether, and even more remain at risk of closure, which will undoubtedly worsen the existing childcare inaccessibility crisis. 23 Worsening Gender Disparities During COVID-19

COVID-19 has only magnified existing gender disparities. Despite the increased domestic and childcare burdens placed on working mothers, most fathers do not perceive differences in work distribution. 24 Single HCW parents, who are more often women and people of color, have no option to share domestic responsibilities. 25 In addition, compared with women, men are paid more, 25 have less risk of furlough, 26 and more often work in occupations that can be transitioned to telecommuting, allowing them to work from home. 26 Even when both members of heterosexual couples work from home, men's work responsibilities are often prioritized over women's. 27 Residents are particularly affected by gender disparities. Several surveys have illustrated that women trainees are less likely to have partners who do not work full-time. For example, a 2014 survey of radiation oncology residents with children found that nearly 40% of men had partners who did not work compared with 0% of women. 28 A much larger survey of early career physician recipients of K awards across all specialties had similar findings; men were approximately 4 times more likely to have spouses or domestic partners who were employed part-time or not at all. 29 In the same study, approximately 85% of women had spouses or domestic partners who worked full-time compared with 44% of men. 29 Women physicians also have cautioned women medical students against choosing specialties that are less supportive of starting or growing a family. For example, one-third of general surgery residents reported that they would discourage women medical students from pursuing a surgical career due to "difficulties balancing pregnancy and motherhood with training. " 30 This lack of support has drastic consequences for residents amid COVID-19. Many of these young physicians have reported working without access to childcare, hazard pay, or adequate PPE. 31, 32 Even when PPE is available, most women must make do with ill-fitting products designed to fit "standard" male proportions. 33 In addition to being a nuisance, ill-fitting protective gear poses a serious danger for disease transmission. 33 Compared with their women peers, men in academia have increased their scholarly productivity during COVID-19. 34 Already disadvantaged, delayed manuscript preparation, canceled speaking opportunities, and decreased access to mentorship will undoubtedly hinder women's academic career advancement, possibly erasing decades of recent progress.

Given the numerous ways that COVID-19 has exacerbated existing gender disparities, it is unsurprising that women's mental health has been more severely affected by the pandemic than men's. A survey conducted in Wuhan, China, during the earliest stage of the pandemic (January 2020) found that COVID-19 led to a disproportionate increase in depression, anxiety, insomnia, and distress among HCWs, particularly women. 35 As the pandemic progressed, HCWs in the United States experienced similar mental health effects. One study of physician mothers conducted in April 2020 found that more than 40% met the diagnostic criteria for moderate or severe anxiety. 36 In addition, anecdotes from young physicians highlight their exhaustion, feelings of imposter syndrome, selfdoubt, inadequacies, and symptoms of posttraumatic stress disorder. 37 An American Enterprise Institute survey of 3,500 adults conducted in May 2020 found that approximately 51% of mothers endorsed feeling depressed at least a few times over the prior week compared with 35% of fathers. 38 That same survey found that COVID-19 is taking a devastating toll on single-parent households; compared with parents in dual-parent households, single parents are experiencing far greater levels of emotional distress, depressed feelings, and incidences of crying throughout the week. 38 The increased stress that the COVID-19 pandemic has placed on HCW parents is likely affecting their children. When parents or guardians have job instability, adverse work conditions, or nonstandard duty hours, their children are more likely to have elevated emotions and increased behavior difficulties. 39 In addition, psychosocial stressors in infancy and early childhood can alter developmental trajectories, increasing later risk for developmental delay, mental health issues, and metabolic diseases. 40 The full impact of COVID-19 on child development cannot be known yet, but some children are more at risk than others. Disabled children are particularly vulnerable, as the relatively few resources available to them before COVID-19 have been upended. 41 Due to school and day care closures, the majority of stress experienced by children during the pandemic must be mitigated solely by parents and guardians. This is taking a toll on the mental and physical health of both children and their families. 42, 43 The American Enterprise Institute aptly named its report "The Parents Are Not All Right. " 38 Without assistance, HCWs and their families will continue to suffer.

Per the National Academies of Sciences, Engineering, and Medicine, public health efforts must address the social determinants of health to increase community resilience to environmental and infectious disasters. 44 This includes access to childcare, according to the American Academy of Family Physicians. 45 Unfortunately, the absence of government-supported childcare 46 has left the United States ill prepared to address the ramifications of school closures due to COVID-19, which has directly impacted frontline HCWs. According to Dr. Walter Gilliam, a professor of child psychiatry and psychology at Yale University, "When doctors and [intensive care unit] nurses and other important workers don't have child care, people may die. " 47 The lack of a childcare entitlement program in the United States stands in stark contrast to other Organization for Economic Cooperation and Development (OECD) countries, where childcare is often a government-provided service. 48 For example, in March 2020, the government in the United Kingdom mandated that the education sector organize free childcare for essential workers, allowing parents to drop off their children at school while they went to work. 49 In the United States, however, the federal government has yet to enact legislation mandating access to childcare for essential workers, even a year into the pandemic. In addition, the United States is one of only a few countries in the world and the only OECD member without federally mandated paid family leave 50 ; parental or caregiver leave and assistance for dependent care are entirely at the discretion of individual employers. Government support for the childcare sector and for HCW parents in particular is urgently needed. We call on the American Medical Association, Association of American Medical Colleges (AAMC), and other organizations representing health care professionals to advocate for such support for HCW parents, especially during COVID-19.

Benefits for HCWs during the pandemic have varied greatly; some health care organizations have instituted changes to better support their workers, while others have removed benefits. 51 An August 2020 survey of AAMC member institutions found that, among responding organizations, fewer than half provided any childcare assistance before COVID-19. Of those, 62% (18/29) had expanded childcare options during the pandemic. However, of the 27 organizations (46%) that provided no childcare assistance before COVID-19, only 2 expanded their support. 52 Additionally, organizations that created new childcare policies have struggled to implement them. 47, 53 These observations suggest that, without government support for childcare-or at a minimum, legislation mandating employer-sponsored childcare-many HCWs will continue to struggle to find adequate and accessible childcare.

Providing childcare options benefits both organizations and their employees. A 2019 report from the Council for a Strong America estimated that employers lose approximately $13 billion annually in potential earnings due to the childcare challenges faced by their workforces. 54 Parents are often forced to leave work early, show up late, or even miss full days of work when they cannot find adequate childcare. 54 Amid COVID-19, these barriers have increased exponentially, and health care organizations that fail to support HCW parents could risk losing these workers altogether.

Unfortunately, there is not a one-sizefits-all solution to childcare provision at the employer level. Organizations must consider their workers' needs to adequately support them at any time but especially during COVID-19. For example, some HCWs may benefit more from in-home nannying services, while others may prefer day care centers. Flexible structures that incorporate childcare options for disabled children and 24/7 work schedules are vital. Failure to support HCW parents at this time poses a great risk to patient care, as many parents are being forced to choose between staying home to care for their children and going to work to care for their patients. The true impact of this childcare crisis, however, may be going unrecognized or at least unmeasured; only 9 of 59 organizations in the recent AAMC survey cited above reported tracking the effects of childcare availability on rates of employee turnover. 52 While organizations and the government work to develop a more stable system of childcare options, newly formed volunteer groups are offering short-term solutions. 55 Some of these groups, led by health professions students, provide free childcare to essential workers. 56 For example, a group of primarily women medical students (including L.J.R. and B.J.E.) created MN CovidSitters, a nonprofit that uses technology to link student volunteers with HCWs in need of childcare. 57 While these efforts are important, they are a temporary fix to a broken childcare system. For too long, politicians have assumed that child care and elderly care can be "soaked up" by private citizens-mostly women-effectively providing a huge subsidy to the paid economy. This pandemic should remind us of the true scale of that distortion. 58 Conclusion James Brown croons, "it wouldn't be nothing, nothing without a woman or a girl. " 1 Yet, our health care system is failing its women HCWs and, as a result, many plan to leave or have already left health care altogether. Working mothers-particularly trainees, junior faculty, and those from rural and lower socioeconomic areas-are making increasingly desperate calls for additional family support. 7 Without immediate assistance, these HCWs and their families will continue to struggle. Lack of access to affordable childcare is hindering HCWs in doing their jobs, including conducting and publishing academic scholarship. This poses incalculable risks to families, science, and society.

The United States cannot continue to rely on a crumbling childcare infrastructure. COVID-19 should serve as a call to action to all sectors, including the government and private employers, to prioritize and increase support for vulnerable populations like women and children. As a country and a house of medicine, we must care for the families of HCWs while they continue to care for our families.

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