INTRODUCTION
Because I am a primary care doctor in a mid-sized industrial city in the northeastern United States where small manufacturing still exists (although the unions and the mills and factories where my patients’ parents worked have mostly disappeared), I often see people who work with their hands. My patients are the frontline workers who remain hidden from top-income Americans; they live in neighborhoods I don’t know. Few of my patients are in the nation’s highest income strata. In 2019, the year before COVID-19 arrived, 62 percent of people in the top quarter of American income were able to work remotely, as opposed to 9 percent of the bottom quarter. Based on this simple statistic, anyone could have predicted that an airborne infectious agent would affect these essential occupations disproportionately.
In 2020, the first year of COVID-19, deaths differed by occupation in the United States. The highest death rates were seen, by risk order, in construction workers, transportation workers (public transit, trucks), retail workers (grocery, convenience, drugstore), correctional officers, home health aides, nurses, cooks, factory workers, and material movers (bulldozer operators). In the news reports and statistics, people filling these jobs requiring physical labor were called “frontline workers” or “essential workers.” Essential work was typically low-wage labor that was taken for granted, mostly invisible to those who could work remotely from home. People of color were more likely than other workers to be in essential jobs. During COVID-19, essential meant “obligatory” for those who took the daily risk of getting sick in order to support themselves and their families. They worked paycheck to paycheck, meal to meal. COVID-19 shone a spotlight on the special risk to the well-being of certain workers. But as that attention fades, we are likely to forget the demanding physical labor of these individuals even as the national retirement age creeps past sixty-five and our national policies ask them to work longer, continuing the toll on their bodies.
Two-thirds of Americans do jobs that require physical labor. During the worst of the COVID-19 outbreak, it became clear that many jobs could potentially kill you. Following the pandemic years and the death-by-occupation data I learned, I found myself asking my patients more than I thought I ever would about their work, which so notably drives physical and mental health, and more clearly than ever before—even in non-pandemic times—delineates identity and complicates our notions of equality and fairness.
Are you working now?
Why not?
Do you ever go to work sick?
What part of work do you like the most? Hate the most? What did you want to be when you were sixteen?
Do you imagine retiring?
Do you think you will ever be able to retire?
For all of us, our job is what we know best. But its peculiarities are unknown to others. My patients talk to me about jobs I am familiar with and jobs I didn’t know existed. The conversations I’ve written down here come after a pandemic that killed over one million Americans, some of them my former patients.
I spend my life as a doctor at work in this circular suite of offices, among a small group of medical colleagues, shuttling between nearly identical examining-tabled rooms, going round and round like a bobbing piece of wood in the eddies of my day. But it doesn’t feel repetitive like the factory work I hear about. Each patient feels like the first and only one. Every day I must get things right when I diagnose and treat, and I hope I get very few very wrong. It is a high bar—the challenge must remain a fixation for me to do this work well. My patients take time off from work (unpaid) to see me, so I always take them seriously.
My patients are not hard for me to like; they display their best behaviors with me. I’ve always admired people who are good at things I am not—mechanics who understand engines, people who know how to build a house. I like to be able to tell my patients who barely finished high school that they are experts at things I have no aptitude for, that they can see things that I can’t, that their work is a richly layered skill. This makes them smile even if they’re thinking: This doctor here still makes more money than I do, the lucky bastard. But they know I’m right. As a patient once said to me, “Guys with high school degrees fix things. Guys with college degrees screw things up.” To which I answered, “You better hope that’s not the case here.”
Many of my patients to my office directly from work. They wear stiff, steel-toed boots, donut shop uniforms with first name pins, florescent-green road-crew vests, waiters’ black pants with a sheen, heavy flannel shirts, canvas overalls, company insignia on white polos, knee pads. They wear dust and paint drips, tomato sauce and soot, oil stains and plaster nibs; they smell of coffee and sweat, overheated machines and cigarettes. During an exam, my nose is close to their scalps. With each visit, I rediscover the pungency of direct patient care in this place that between visits smells sweetly of spray disinfectant and leftover brownies. My exam room is clean and orderly until they put their helmets and belts and knapsacks and keychains down on the chairs. I have seen these patients of mine hurt and bloodied from work in factories, nursing homes, boat yards, and warehouses, on trucks and train tracks. Sometimes, their work leaves fingers broken, knees swollen, wrists burnt, shoulders dislocated, fore- arms numb—or it takes away years. But I’ve also seen my patients hurt by not working—this is its own affliction with a particular emotional toll. Work can heal them too.
Copyright © 2025 by Michael D. Stein. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
