Revista Brasileira de Saúde Ocupacional ISSN: 0303-7657 ISSN: 2317-6369 Fundação Jorge Duprat Figueiredo de Segurança e Medicina do Trabalho - FUNDACENTRO

Vedovato, Tatiana Giovanelli; Andrade, Cristiane Batista; Santos, Daniela Lacerda; Bitencourt, Silvana Maria; Almeida, Lidiane Peixoto de; Sampaio, Jéssyca Félix da Silva Trabalhadores(as) da saúde e a COVID-19: condições de trabalho à deriva? Revista Brasileira de Saúde Ocupacional, vol. 46, e1, 2021 Fundação Jorge Duprat Figueiredo de Segurança e Medicina do Trabalho - FUNDACENTRO

DOI: https://doi.org/10.1590/2317-6369000028520

Available in: https://www.redalyc.org/articulo.oa?id=100566937001

How to cite Complete issue Scientific Information System Redalyc More information about this article Network of Scientific Journals from Latin America and the Caribbean, Spain and Journal's webpage in redalyc.org Portugal Project academic non-profit, developed under the open access initiative Revista Brasileira de Saúde Ocupacional Research article/ ISSN: 2317-6369 (online) Dossier COVID-19 and Worker’s Health http://dx.doi.org/10.1590/2317-6369000028520

1 Tatiana Giovanelli Vedovatoa Health workers and COVID-19: flailing working https://orcid.org/0000-0001-8615-1317 Cristiane Batista Andradeb conditions? https://orcid.org/0000-0003-1441-9171 Daniela Lacerda Santosc Trabalhadores(as) da saúde e a COVID-19: https://orcid.org/0000-0002-6318-0809 condições de trabalho à deriva? Silvana Maria Bitencourtd https://orcid.org/0000-0002-3183-373X Lidiane Peixoto de Almeidae Abstract https://orcid.org/0000-0003-4130-3086 Jéssyca Félix da Silva Sampaiof Objectives: to analyze the working conditions of health professionals facing https://orcid.org/0000-0003-0304-7122 the COVID-19 pandemic in Brazil based on online media reports published in prominent news portals. Methods: qualitative analysis of 22 news stories selected a Pontifícia Universidade Católica de from two of the main Brazilian news portals, published between April 20 and 30, Campinas (PUC-Campinas). Campinas, 2020. Based on thematic content analysis, we defined five categories: Personal SP, Brazil. Protective Equipment (PPE) and COVID-19; health workers with comorbidities b Fundação Oswaldo Cruz (Fiocruz), working on the front line; illness and death due to work; access to treatment and Centro Latino-Americano de Estudos work leave due to COVID-19; resigning from work and professional updating. de Violência e Saúde Jorge Careli. Results: the news stories reported inadequate working conditions due to lack Rio de Janeiro, RJ, Brazil. of and/or inadequate PPE; health care workers with comorbidities remaining at c Centro Universitário Arthur Sá Earp work; sickness and death from COVID-19; strain and fear of being infected, and Neto (UNIFASE), Saúde Coletiva. having to deal with co-workers’ sickness and death; difficulties in getting tested Petrópolis, RJ, Brazil. for COVID-19 and obtaining sick leave for treatment; resigning from health care d Universidade Federal de Mato Grosso work; need for fast professional updating for COVID-19 health care. Conclusion: (UFMT), programa de pós-graduação the pandemic clearly evidences the need for public investment in health care for em Sociologia. Cuiabá, MT, Brazil. workers in charge of caring for the population. e Universidade Federal do Rio de Keywords: working conditions; infection by coronavirus; personal protective Janeiro (UFRJ). Rio de Janeiro, RJ, Brazil. equipment; mass media; occupational health. f Prefeitura do Rio de Janeiro. Rio de Janeiro, RJ, Brazil. Resumo Corresponding author: Tatiana Giovanelli Vedovato Objetivos: analisar as condições de trabalho dos profissionais de saúde Email address: que atuam na pandemia de COVID-19, no Brasil, com base em reportagens [email protected] publicadas na internet por veículos de comunicação jornalística. Métodos: análise qualitativa de 22 reportagens selecionadas de dois dos principais portais The authors declare that the work de notícias brasileiros, publicadas entre 20 e 30 de abril de 2020. Por meio da was not funded and that there is no conflict of interest. análise temática de conteúdo, foram definidas cinco categorias: Equipamento de Proteção Individual (EPI); profissionais de saúde com comorbidade na linha de frente; adoecimento e morte pelo trabalho; acesso ao tratamento e afastamento The authors inform that the study was not presented at any scientific event. do trabalho; desistência do trabalho e atualização profissional. Resultados: as reportagens evidenciaram condições de trabalho inadequadas por ausência e/ou precariedade dos EPI; continuidade do trabalho de profissionais de saúde com comorbidades; adoecimento e mortes pela COVID-19; tensão e medo de serem infectados(as) e de lidar com o adoecimento e morte de colegas; dificuldades no acesso aos testes de COVID-19 e para afastamento do trabalho para tratamento; desistências de trabalhar na atividade; necessidade de atualização rápida para o cuidado em saúde na COVID-19. Conclusão: o cenário pandêmico deixa evidente a necessidade primordial de investimento público no cuidado daqueles(as) que estão à frente dos atendimentos à população. Palavras-chave: condições de trabalho; infecção por coronavírus; equipamentos de proteção; meios de comunicação de massa; saúde do trabalhador. Received: August 22, 2020 Reviewed: November 4, 2020 Approved: November 9, 2020

Rev Bras Saude Ocup 2021;46:e1 1/15 Introduction supplies and machinery. Thus, it is through working conditions that labor market aspects In late January 2020, the World Health Organization are analyzed (hiring, career stability, as well as 6 (WHO) declared the Covid-19 outbreak, caused by safety and health risks during the work routine) . the new coronavirus SARS-CoV-2, a public health And due to precarious working conditions, emergency, characterizing it as a pandemic in March occupational illness is a reality in several areas. 20201, which brought about changes in people’s way It is up to labor management to provide dignified of life and in daily health care practices worldwide. On and safe conditions to preserve the health of all that occasion, people were recommended to follow workers, particularly in the context of a pandemic, the protective measures published by WHO in order in which the risk of contamination by the new to prevent the large-scale spread of the virus and the coronavirus is one of the challenges for health collapse of health systems, whose resources were care and labor management professionals. no longer sufficient to deal with the large number of Another issue concerns the health care infected people. workers’ pay in Brazil, considering that precarious In addition, the COVID-19 pandemic raised employment is a reality in this sector due to low global awareness of the health care work done wages, outsourcing, work overload, fear of job loss, by doctors, nurses and nursing technicians, as well as poor working conditions7. Therefore, physiotherapists, psychologists and social low wages mean that workers need to have more workers, who are at the forefront of disease than one job, accumulating shifts in different prevention programs and care of the most serious health institutions in an attempt to make ends cases. According to the Brazilian Federal Nursing meet. That said, the fact of having more than one Council (Cofen), on December 1, 2020, there were job can lead to physical and mental strain. 43,788 infected people and 460 deaths among health professionals (63.9% women)2. These Discussing work in the field of health care figures alone give an idea of the difficulties and requires understanding that the work process, as violence related to the working conditions endured well as its conditions, is closely related to health, by these workers in Brazil. for according to Thébaud-Mony8. it is “a process that marks the body, the person, with the signs of The increase of COVID-19 cases and the work, of living conditions, of pains, of pleasure intensification of health care work have created a and suffering, of everything that comprises an worrying and health-threatening scenario for these individual life story in its singularity, but also professionals, who therefore need an adequate collective by the influence of multiple logics provision of Personal Protective Equipment (PPE) surrounding the it” (p. 220)8. and training in how to use it3. After the beginning of the pandemic in Brazil, COVID-19 requires specialized care, especially numerous news stories were published on social for patients who need to be admitted to intensive networking sites and in news media describing care units (ICU), many of them on ventilators the working conditions of Brazilian health care due to pulmonary impairment. In addition to professionals on the front line against COVID-19. providing such care for sick people, health workers, especially those on the front line, have to Thus, the objective of this study is to analyze take difficult decisions regarding the treatment of the working conditions of health workers who their patients. And, at the same time, they witness have provided health care during the COVID-19 co-workers being put on leave due to infection pandemic in Brazil, based on online media reports by COVID-19, which ends up by causing work published in prominent news portals. overload. In this sense, offering adequate working conditions is a crucial factor for preserving these professionals’ health during this pandemic4,5. Methods

We understand working conditions as This is a qualitative study that draws on news situations related to physical and material media to apprehend the narratives of workers resources needed to carry out work, such as providing care for people diagnosed with COVID-19.

2/15 Rev Bras Saude Ocup 2021;46:e1 At the beginning of data collection, the Correio Content Analysis (AC) was used to investigate Braziliense, Folha de São Paulo and O Estado de São the workers’ narratives10. As recommended by Paulo newspapers, and the Terra, G1 and Uol portals Minayo11, the first stage of CA consisted of pre- were used as sources of online media. However, with analysis by skimming the collected material and the exception of the last two cited outlets, the news building the text corpus, with the research team media consulted had a reduced number of stories paying special attention to the initial goals. Then and did not provide enough information to address we explored this material, actively searching the object of this study. On the other hand, the G1 for main expressions, their meanings and the portal contained news stories (broadcast and text) narratives main actors selecting theoretical/ on the working and health conditions of workers analytical categories, among other activities. In on the front line of care against COVID-19 in all the last stage we decided how to treat the results Brazilian regions (capitals and countryside cities), and their interpretations11. with statements by health professionals, managers and representatives of trade unions and professional For this last stage we defined five analytical councils (especially of medicine and nursing). categories related to the reality of the health workers’ working conditions due to their care Thus, we used news stories (text and broadcast) against COVID-19: PPE and COVID-19; health g h from G1 and Uol on the working and health workers with comorbidities on the front line; conditions of such professionals, selected by using illness and death due to work; access to treatment the keywords, in Portuguese, “COVID-19” and and work leave due to COVID-19; resigning from “profissiona*.”, both in singular and plural form. work and professional updating for COVID-19.

The selected reports were published between This research is part of the project entitled April 20 and 30, 2020. The time frame was “Work, health and emotions: health workers faced necessary in view of the number of reports on the with COVID-19,” which was analyzed by the topic during that period. We selected 41 from G1 Research Ethics Committee (CEP) of the National and 7 from Uol, totaling 48, 22 of which used in School of Public Health of the Oswaldo Cruz the analyses of this study. Foundation and received approval n. 06/2020, It is noteworthy that news media have already issued on May 5, 2020, as it concerns the analysis been used in a study on pandemic. In that case, the of public and open data. authors indicated the possibility of shedding light on “the subject’s inner self, his feelings, reports of actions and so on” (p. 62)9. When choosing texts Results and discussion for analysis, we used indirect and direct speech in order to grasp the purposes of experiences, to Chart 1 features an overview of the COVID-19 understand specific topics and to address our pandemic in Brazil: decrees, federal government decisions, number of cases and deaths, theme through the narratives, i.e., to make the professional associations, among others. experiences of health workers and their context visible. News stories make it possible to apprehend Chart 2 features the main news stories used in the feelings, experiences, fear of illness and death this research. From the 48 news stories, 22 were and family routines in the face of a pandemic9. selected for this article.

g Available from: www.g1.globo.com. h Available from: www.uol.com.br.

Rev Bras Saude Ocup 2021;46:e1 3/15 Chart 1 Summary of events related to the COVID-19 pandemic in the period of data collection in news media

Date Event Developments Global obligation to adopt measures to prevent and March 11, 2020 WHO declares COVID-19 a pandemic1. control the disease1. Rio de Janeiro and São Paulo (capitals) already Changes in protocols to identify suspected cases and March 16, 2020 had cases of community transmission12. reorganization of services due to increase in cases12. Cofen creates a form to notify suspected Illness of workers on the front line is afforded visibility, showing and/or confirmed cases of COVID-19 the importance of discussions related to their work. Other councils March 30, 2020 among health workers. Creation of the did not follow suit, making it difficult to analyze the situation of “Nursing Observatory” to monitor cases multidisciplinary health teams2. among workers2. The Federal Supreme Court (STF) grants an injunction requested by President Jair Bolsonaro diverges on the Brazilian Bar Association (OAB) ensuring the power of states, the issue of social distancing from April 8, 2020 municipalities and the Federal District to make decisions to face recommendations and decisions taken COVID-19, such as restrictions on movement of people, closing of by governors and mayors13. schools, shops and other activities13. The Oswaldo Cruz Foundation, The observatory was created as a channel for the disclosure of data April 9, 2020 a public health institution, creates the and studies and integration with other projects14. “COVID-19 Observatory.”14 Political disagreements between President Bolsonaro and Health Minister Luiz Henrique April 16, 2020 The health minister is dismissed in the midst of the pandemic15. Mandetta over actions and guidelines for coping with COVID-1915. Following disagreements with the president regarding the use of chloroquine, Nelson Teich resigns 29 days after his being appointed. The new health minister, Nelson Teich, No new health minister is appointed for 17 days16. April 17, 2020 takes office. Eduardo Pazuello assumes as interim minister and is officially appointed in September17. April 30, 2020 85,380 confirmed cases18. 5,901 deaths from COVID-1918.

Chart 2 Selected news stories and information related to the working conditions analytical categories

Resigning from work Workers with Access to treatment Illness and death and professional Title, source and date PPE and COVID-19 comorbidities on and work leave due to due to work updating for the front line COVID-19 COVID-19 Death of technicians from Health professionals COVID-19 at the Osid Death of Scarce or put on leave due hospital causes apprehension two nursing Reports about fear inadequate PPE, to COVID-19. among workers: Worker is No information. technicians and of contagion and according to Psychological support, resigning19. workers get ill resignation. workers. according to labor from COVID-19. management. G1, on April 30, 2020. Almost 50% of health care workers heard by Public Labor Prosecutors in Minas Gerais Lack of adequate Doctors and nurses report that workers with gowns and N95 No information. No information. with COVID-19 are not No information. symptoms of COVID-19 are masks. granted leave. not granted leave20.

G1, on April 30, 2020. (Continued)

4/15 Rev Bras Saude Ocup 2021;46:e1 Chart 2 Continuation...

Resigning from work Workers with Access to treatment Illness and death and professional Title, source and date PPE and COVID-19 comorbidities on and work leave due to due to work updating for the front line COVID-19 COVID-19 More than 2,200 health workers in RJ were put 2,200 at-risk Death of health on leave with suspected health workers workers (11 Workers with COVID-19 contagion or for No information. with suspected doctors and 18 COVID-19 put on No information. belonging to risk groups21. contagion were nurses) from leave. put on leave. COVID-19. G1, on April 30, 2020. Lack of and inadequate PPE Nurses protest against lack of (face masks Availability of PPE to care for patients with and gowns), Training courses COVID-19 tests for COVID-1922. according to the No information. No information. were offered to health care workers is workers. Labor about 60 workers. reported. G1, on April 25, 2020. management reports purchase of PPE. Death of a More than 250 health care 250 workers 61-year-old workers tested positive for tested positive The nursing assistant nursing assistant COVID-19 in Maranhão23. No information. for the disease, who died from the No information. with diabetes 127 recovered disease was on leave. and obesity. G1, on April 25, 2020. and 6 died.

Workers report psychological stress, fear, panic Health workers face fear and Lack of and More than 7 thousand syndrome, Workers are pressure in the fight against inadequate PPE health workers put on psychic resigning, coronavirus24. (face masks and No information. leave. Psychological distress, use according to a gowns), according support for health of anxiolytics doctor. G1, on April 26, 2020. to the workers. workers. and/or anti- depressants and insomnia. Death of 53 nurses. Reports of cases Reports that of depression, Every 11 minutes, a nurse health workers panic Difficulty to obtain Workers report working in care against over 60 are syndrome, sick leave for lack of training to COVID-19 seeks psychological Shortage of PPE. denied leave for anxiety, stress, COVID-19 treatment care for patients assistance25. COVID-19 or insomnia, and/or mental health with the new psychological exhaustion problems. coronavirus. G1, on April 24, 2020. problems. and fear of contagion. Psychological Paraná has 63 staff of state 63 health workers symptoms hospitals on leave due to Shortage of PPE on leave due to the such as fear of COVID-1926. and hospital No information. disease. All staff with No information. contamination. equipment. symptoms are placed Underreporting G1, on April 24, 2020. on leave. of illness cases. Report that In two days, the number of 284 health no training for health workers with COVID-19 workers One worker reported COVID-19 care increases 66% in ES27. Shortage of PPE. No information. contaminated to be on leave. was offered at the by COVID-19. outbreak of the G1, on April 22, 2020. pandemic. (Continued)

Rev Bras Saude Ocup 2021;46:e1 5/15 Chart 2 Continuation... Resigning from work Workers with Access to treatment Illness and death and professional Title, source and date PPE and COVID-19 comorbidities on and work leave due to due to work updating for the front line COVID-19 COVID-19 Shortage of Reports of Staff of the Miguel Couto or inadequate death of Hospital at risk for COVID-19 PPE, according At-risk health workers, say they have not been given to workers. workers are not including No information. No information. leave28. The hospital given leave. those at risk management says (diabetes) for G1, on April 23, 2020. PPE is sufficient. COVID-19. 11 nurses Report that Coronavirus: nurses in Rio dead and Lack of tests for health services claim lack of support and Shortage of and 548 on leave. workers suspected of management equipment in ICU29. inadequate use of Emotional COVID-19 contagion. No information. ignores which PPE. symptoms Difficulties to obtain workers are at G1, on April 23, 2020. like fear and psychiatric care. risk. depression. President of the medical Death of health association talks about Recently graduated Shortage of PPE workers from contamination of workers by health workers and hospital No information. COVID-19 No information. COVID-1930. called to assist in supplies. and fear of the pandemic. contagion. G1, on April 23, 2020. 45 workers Courses on Number of health workers infected by the donning and with COVID-19 in Paraíba Importance of Purchase of COVID-19 disease. removing increases 66% in one week31. having adequate No information. tests for health care Death of health PPE to avoid PPE for workers. workers. workers from contamination of G1, on April 22, 2020. COVID-19. workers. Report of purchase of PPE and hospital Death of a sanitization and nurse who was cleaning products. on leave due 58-year-old nurse is the first to contagion; health worker to die from Shortage of PPE. 52 nurses placed according COVID-19 in Amapá32. No information. on leave due to No information. to family Complaints of contagion. members, G1, on April 22, 2020. water shortage she was not in the hospital contaminated in environment, the workplace. denied by hospital management. ES records 101 new cases and totals 1,313 people infected 206 health by COVID-19; 206 are health workers No information. No information. No information. No information. workers33. infected by coronavirus. G1, on April 21, 2020. Six deaths and around 1,800 RJ has 6 deaths and more than health workers 1,800 health workers on leave on leave due due to COVID-19: “It took a to COVID-19. piece of us,” says the victim’s No information. No information. No information. No information. Symptoms daughter34. related to COVID-19 and G1, on April 21, 2020. feelings of sadness. (Continued)

6/15 Rev Bras Saude Ocup 2021;46:e1 Chart 2 Continuation... Resigning from work Workers with Access to treatment Illness and death and professional Title, source and date PPE and COVID-19 comorbidities on and work leave due to due to work updating for the front line COVID-19 COVID-19 There have been 12 deaths 12 health workers in São Paulo from COVID-19 Need to purchase have died from COVID-19, says in the capital PPE to provide city official35. No information. city of São No information. No information. care for the Paulo. 3,336 disease. G1, on April 21, 2020. workers are on leave due to the disease.

Workers in at- More than 4,000 nurses have About 4,600 risk groups must been contaminated with Shortage and nurses Approximately 500 be removed COVID-1936. inadequate use of contaminated workers placed on No information. from contact PPE. with the new leave per day. with people with G1, on April 20, 2020. coronavirus. COVID-19.

68-year-old hospital cleaner is Hospital cleaning Testing for the entitled to Covid testing but Shortage and worker member One worker disease is required, cannot get a test37. inadequate use in at-risk group fallen ill with especially for workers No information. of PPE is denied leave COVID-19. in direct contact with Uol, on April 28, 2020. from work. COVID-19.

In Pará, 42% of confirmed Almost half Permanence of No training to coronavirus cases are in the of COVID-19 at-risk workers provide health care health care field38. Shortage of PPE. cases are health No information. in COVID-19 for people with workers, seven care. COVID-19. Uol, on April 28, 2020. of them died.

Technician resigns from A nursing hospital in RJ: “I’ve never technician quits experienced anything like Shortage of PPE. No information. No information. No information. her job due to this.”39 poor working conditions. Uol, on April 29, 2020.

Work overload PE has waiting list for ICU; due to increase workers already have to in cases of the Need to hire health choose who to admit40. No information. No information. disease, which No information. care staff. can lead to Uol, on April 29, 2020. occupational illness.

PPE and COVID-19 Thus, to face COVID-19, health care workers must wear PPE, which should be provided by health From the outset of the pandemic, international institutions to all workers for free43. It consists of organizations have argued that health care workers surgical and breathing protection face masks (N95, are people who are in close contact with the new N99, N100, PFF2 or PFF3 respirators), eye and face coronavirus and therefore considered a group at high protectors, gown or apron and hood44. risk of contagion by the disease. They are the ones who, by providing health care, carry out invasive procedures After reading the 22 reports in full, we observed that such as intubation, collection of lung secretions, in 15 of them, health workers from different parts of bronchoscopies, among others41,42, which evidences Brazil mentioned the main problems they were facing the need to protect these workers’ safety and health . at the time regarding the adequate PPE provision:

Rev Bras Saude Ocup 2021;46:e1 7/15 We sign a receipt for the N95 mask and googles. the beginning of the pandemic, Cofen has purchased And then, from the moment you sign it, you can’t get 86 thousand face masks that are being distributed by another mask. So you have to keep that one, I don’t Coren according to the needs of each Brazilian state, know how long, which is already wrong, because the mainly to public institutions46. N95 has an expiry date29.. Another aspect reported by health workers that We noted the issue reported by these workers in increases COVID-19 contagion relates to removing PPE: having to submit to this condition which does not ensure adequate protection. The National Health When it comes to removing the equipment, people Surveillance Agency (Anvisa), which regulates the are careless and become contaminated. So right now equipment, materials and drugs used in Brazil, we are gathering staff from all facilities for a huge training session on how to put on and remove the published Technical Note no. 04/202045. This note equipment, so that it can be done safely31. contains guidelines for Brazilian health services regarding preventive and control measures to be As for the curtailment of hospital medical adopted when providing care for suspected and products, besides PPE, shortage of supplies such as confirmed cases of infection by the new coronavirus paper towels and alcohol was also reported. As a (SARS-CoV-2), including on the extended use of the result, Coren intervened to force state and municipal N95 mask: “The use, handling and storage must administrations to make decisions that would follow the manufacturer’s recommendations and it preserve the workers’ health. It was mentioned that 45 must never be shared among workers” (p. 30) . Coren filed a lawsuit to ensure PPE for workers However, there are constant complaints from on the front line against COVID-19 in one of the workers about the shortage of PPE20,35 in health Brazilian states, after receiving complaints that care facilities in general, due to the greater demand workers were not being provided with equipment in and poor supply available for health services, as that state health centers32. noted below: According to Anvisa, prevention and control measures, including the correct use of PPE, must Many still complain about the lack of working equipment, the shortage of PPE and supplies is a be adopted in care provided to suspected or global problem everywhere30. confirmed cases of infection by the new coronavirus (SARS-CoV-2)45. Therefore, we enquired how In view of this situation experienced in Brazilian health systems were handling the distribution, health institutions due to the COVID-19 national maintenance and use of PPE to ensure the safety of public health emergency, Anvisa updated the staff working on care against COVID-19. Technical Note no. 04/2020 on May 8, 2020, extending some PPE lifetime, such as N95 masks or equivalent. Health workers with comorbidities on the front line These face masks could then be used for a longer According to the analyzed news stories, health period than provided by the manufacturer. However, workers with comorbidities were on the front line. this could not be used as a strategy by health services to justify the faulty distribution of PPE to workers. The severity of COVID-19 has been linked The Hospital Infection Control Committees (CCIH) to diabetes, heart conditions, respiratory and must take charge of regulating health services together immunosuppression problems47. Some issues and with the technical staff of each health care facility45. complaints were highlighted by the media, and also by workers who had one or more of these diseases and There are some professional councils, such as continued their care activities, despite the greater risk Cofen and the Regional Nursing Council (Coren), of becoming seriously ill by the coronavirus. which, due to constant complaints (over 8 thousand) from their members, intensified their inspection We noted the risks to which the workers are efforts (more than 7 thousand inspections). In one of subject during the pandemic. The feeling that they the news stories, a Coren representative reported: “We were risking their lives to care for “others” was come across facilities that are not providing adequate observed among the 572 complaints from health face masks, that are reusing waterproof aprons, and workers (doctors and nurses) sent to the Public we also noted the distribution of raincoats to workers Prosecutor’s Office of Rio de Janeiro: 48% of them instead of waterproof aprons, which is not appropriate were related to the obligation to continue working either.”24 Thus, due to the complaints received since despite having symptoms of COVID-1920.

8/15 Rev Bras Saude Ocup 2021;46:e1 There was also the case of a pregnant health essential services, as it can be transmitted in daily worker (although it is not considered a comorbidity) commuting on public transport and in contact with who was afraid of catching the virus and passing people at the workplace. To summarize: “COVID-19 it on to the baby, but even so was unable to obtain in workers is presumably related to work” (p. 3), and leave or reallocation. Although there is no scientific health workers in particular must be duly protected evidence of vertical transmission, from the mother to prevent the disease49. It is also essential to report to the fetus or newborn, pregnant women’s mental, all suspected or confirmed cases of the disease49. emotional and physical health must be taken into Many news stories addressed the experiences 48 consideration due to their altered body condition . of health workers with illness and death. One of Anxiety, fear, stress and worry are experienced the findings concerns the need for health labor by exposed workers who were not granted leave, as management authorities to ensure workers’ safety they are aware not only of the risks they run – and and health, not least to ensure continued care36. of infecting family members, especially children Some statements reveal the workers’ concern and elderly parents – but also of the risks to which that illness among health staff may decrease the their colleagues are exposed, especially those number of people providing care, as shown in the suffering from comorbidities and older adults. As following excerpt: one nurse stated: “People leave their shifts and cry in the car, some of them can’t even make it home. Health workers are on the front line and need all the support from health facilities to care well for patients It’s really sad.”25 and not be contaminated. The more doctors are infected, Besides poor working conditions, some workers also the fewer professionals we will have to face this battle36. mention living in fear that they and their colleagues might fall ill, as well as coping with the large number Many reports by workers and different trade of deaths they witness working on the front line: union representatives stressed the number of workers on leave. In some Brazilian regions they I am very concerned because, like my colleague, I accounted for half of the cases in cities and towns. am in a risk group, but I cannot stop working. And We emphasize that the health care sector has I’m not receiving any care, right? The only people been experiencing precarious working conditions, being put on leave are those over 60. But those with a with limited hiring of staff and restricted material comorbidity, pregnant women, none of them are being resources8,49, causing difficulties to those who are on given leave. Today we are numbers, our registration the front line against COVID-1949. numbers are being replaced by headstone numbers29. Concern with their own contamination, their Therefore, workers on the front line with a co-workers’ and workplace was also found in the history of other illnesses experience feelings of fear news stories investigated by this study, increasing and concern in face of a disease that is considered the tension, stress and stigma of being health workers relatively new and, that at the same time can causes and possible “transmitters of the virus,” which was health workers’ illness and death. Such a context favors also reported in another study50. solidarity among health workers, as their professional Deaths among workers were also highlighted: responsibility to fight COVID-19 gives them a sense of community, and they also share their experiences on A lot of people are dying, a lot of nursing staff, a lot of the limits of their bodies and feelings at work. young people, regardless of their age. People who gave their lives to care for others are now dying, every day. Illness and death due to work The situation gets worse and worse34.

Poor working conditions result in complications Although it is important to identify the in workers’ health. This statement is corroborated by occurrence of COVID-19 cases among nursing staff the news stories found in our research, which report to support the organization and development of a high number of health workers falling ill and dying measures to prevent and control the spread of the of COVID-19. virus, a Coren representative confirms in a news story that there is underreporting26. Therefore, we agree with Maeno and Carmo49 who analyze COVID-19 as an occupational disease, Inadequate resting areas were also reported by regardless of whether the occupation relates to health workers. In one state field hospital there was

Rev Bras Saude Ocup 2021;46:e1 9/15 nowhere for nurses to rest other than on the wet Again, they did not test for coronavirus, but the doctor floor: “You’re sleepy, right? And you don’t even have prescribed Tamiflu (an antiviral indicated for severe the right to rest, it’s all wet, right? My God!”24 cases of H1N1) and told her to stay home for seven days. I found it odd, because even without test results, Therefore, as observed by Thébaud-Mony8, we with this pandemic it should be 15 [days]37. emphasize that working conditions can both help preserve the health and cause and intensify the Other news stories mentioned workers with workers’ illness. symptoms being put on leave, but without testing32,33. In addition to difficult access to COVID- Access to treatment and work leave due to COVID-19 19 testing, some news stories mentioned limited access of infected health workers to treatment, even According to the news media, several workers in at the very health facility where they work. “She health centers were placed on leave with suspected didn’t resist infection. She died in a hospital in the COVID-19 infection, and even so they encountered south of the state, because she was unable to get a difficulties to be tested and/or receive treatment, as hospital bed in the capital.”34 shown in the statement below: Another MS document features “recommendations regarding the organization and structuring of work in This is a very worrying fact. There is a huge number of professionals with suspected coronavirus infection health care services to protect health professionals and 52 and fewer than 30% of them are being tested for preserve the workforce” (p. 37) . However, there is no COVID-19. In just one month the regional medicine mention about ensuring access to treatment in case and nursing councils of one state received more than of infection. According to a health care professional 360 complaints from health professionals21. relative: “We searched for the medication for five days. There was none in the public health system or In April 2020, the Brazilian Ministry of Health in drugstores. After a lot of searching, we managed to (MS) issued a document on the distribution and get a packet for R$ 320.”37 availability of COVID-19 rapid tests in states and municipalities, as well as on criteria regarding their Resigning from work and professional updating for use, with priority to health care and public safety COVID-19 workers and people in at-risk groups51. In view of the poor working conditions, resigning To ensure the equitable distribution of tests to from the job was one of the experiences reported states and municipalities, an estimate was made of the by health workers. After only four shifts, a nursing number of health workers in the health care system technician revealed that she quitted due to the as a whole, based on data available from the Unified precarious working conditions. She mentions cases 51 Health System Information Department (Datasus) . of at least five other professionals who made the Although the MS51 document explains the same decision, emphasizing the high number of 39 measures to provide health workers with COVID-19 people being cared for by few staff . In another news testing, many news stories reported difficulties in story in a hospital, it was reported that, following having access to tests: the death of two nurses, many workers were quitting their jobs for fear of contagion19. A big problem here is that we haven’t been tested Quitting the job is not a new issue, since, yet. Testing of patients and especially of those on according to Codo and Vasques-Menezes53, burnout the front line, caring for hospital patients, is not is associated with care activities, especially among happening fast enough30. workers in the fields of ​​education and health, and When a health worker tests positive for COVID- relates to emotional exhaustion (depletion of energy 19, he or she must stay home for 14 days after the and breakdown of affective and emotional bonds); depersonalization (blunting of affective relationships, onset of symptoms; the same procedure occurs negative feelings and expressions); and absence of in case of a positive result for someone in the emotional involvement in work activities53. worker’s household51. However, without testing, only the presence of symptoms can indicate International studies show an increase in another possible illness, which may lead to work demands in the treatment of COVID-19 workers staying away for fewer days. cases, which can lead to physical and mental

10/15 Rev Bras Saude Ocup 2021;46:e1 exhaustion54. This has an impact on the health sectors, exploits workers, putting their lives at risk. of workers, who feel overwhelmed, especially Therefore, what the pandemic situation has shown is when witnessing their co-workers’ death, which the paramount need for care and protection of those generates fear and concern54. who are in charge of health promotion. If there is an increase in the demand of COVID-19 The results presented here, based on news care, there is also a need for training and/or updating stories published in April 2020, at the beginning of professional knowledge in both health care services of the pandemic in Brazil, present situations in (care procedures, request for tests, control of virus which the deficient provision of PPE was reported spread) and self-care, as in the use of personal and by workers in the news media. They evidence the collective protection equipment to prevent the tensions between health labor management and disease. Some health facilities are offering on-site the working class, especially when many workers training, trying to identify when contamination claimed that personal protective equipment was happens and seeking to reduce it, as well as updating lacking, inadequate or insufficient. On the one workers on matters pertaining to COVID-1922,26. Other hand, health management is ensuring protection news stories show the implications of not knowing for society, on the other, health workers are how to deal with PPE: “We were not given adequate experiencing poor working conditions. Therefore, training and were incorrectly removing the PPE”27. what needs to be ensured is the health of these workers. It is unacceptable that there are deaths Another aspect examined was the allocation of related to professional activity! workers from other health care areas to direct care for patients with coronavirus, the hiring of medical Regarding the use of news stories to grasp residents40. We also found reports of cases of the reality experienced by health workers, we intensive care training taking place directly through ascertained that, at the beginning of the pandemic work, as the disease spreads. However, this urgent in Brazil, they emphatically reported health workers’ need for hiring staff causes certain situations: “The illness and death, as well as their precarious problem is the staff being hired for the pandemic, working conditions. Some of them also revealed the without much training, without PPE… These possibility of mental health care for workers, such as people are terrified.”25 initiatives by trade organizations and even hospital labor management, when offering health workers It should be considered that, if on the one hand psychological and/or psychiatric counseling. . there is the possibility of procuring funds to provide hospitals with the necessary medical supplies, on the We realized during this study that the news other it is important to highlight that health workers stories addressed mainly the public health work. are not machines and, therefore, need time for their Therefore, is it also important in our view that media training, above all on how to provide health care and stress the fact that the Brazilian Unified Health look out for their own professional safety in the face System is public and universal, and that, therefore, of COVID-19, which must be a priority and ensured it is up to all sectors, including the news media, to with the provision and guaranteed use of PPE55. demand improvements in working conditions and investment in public health. At a time when the COVID-19 pandemic Conclusions evidenced the need to afford visibility to these professionals, who care for the population’s health, Health care is an essential activity for the it is an ethical, moral and political duty of society, production of health and well-being in a society the State and health institutions to provide these as a whole. Specific professional knowledge and workers with health care, in addition to their social from different fields, when combined, is capable of recognition, not merely by clapping hands, but by providing health prevention, promotion and cure. implementing public policies that provide better However, health work is not dissociated from the working conditions and that are continued even after contradictions of capitalist society, which, in certain the coronavirus pandemic.

Rev Bras Saude Ocup 2021;46:e1 11/15 Authors’ contributions

Vedovato TG, Santos DL, Bitencourt SM contributed to the study design, data analysis, writing, text review and approval of the final version. Andrade CB contributed to the study design, data collection and analysis, writing, text review and approval of its final version. Almeida LP and Sampaio JFS contributed to data analysis, writing, text review and approval of the final version. All authors assume full responsibility for the study and the content herein published.

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