E-consults and Feminist Analyses of the Gig Economy

The papers in the present issue range in topic from the effects of Medicaid expansion on cardiovascular disease disparities all the way to the overlooked medical needs of siblings of children with special health care needs. Here, I will delve into just a few of the issue's papers, several with feminist analyses of the informal work sector and two concerning the growing practice of e-consults.

Informal workers constitute a growing segment of the labor market in the U.S. Sometimes known as independent workers, contract workers, contingent workers, ondemand workers, or gig workers, the category includes domestic workers as well as sex workers, drug dealers, and episodic employees. In some of these sub-groups, women predominate.

A major group of informal workers are non-migrant paid domestic workers (PDWs), among whom women are most numerous. The literature review by an international team led by Germán Guerra covers work on depressive symptoms among PDWs, both quantitative and qualitative. Quantitatively, the literature affirms a high level of depression among PDWs, ranging from 28% to 53%. Qualitatively, the structural conditions of poverty and intersectional discrimination are seen to drive women towards paid domestic work. Together, the quantitative and qualitative analyses in this paper point to psychosocial risks, working conditions, and workplace abuse as moderators of depressive symptoms among PDWs.

Trout and colleagues explore the world of sex workers in Philadelphia through interviews with people from a drop-in support center for cis- and transgender individuals identifying as women. Among the health-related concerns affirmed in the 29 interviews and a follow-up focus group were homelessness, food insecurity, and personal safety. Participants laid special emphasis on a theme the researchers titled, "I am a person."

Truck stops foster informal work of some variety, including sex work and drugdealing, but also "polishers who buff and polish the chrome on trucks, drug pushers, and runners who make drug deliveries and negotiate sales … and peripheral players [such as] people experiencing homelessness and migrant workers who also facilitate these transactions." Through interviews and a survey of an all-male group on health-related issues, Celeste-Villalvir and colleagues conducted research at a series of truck stops in Texas. The resulting themes were (1) substance use, (2) mental illness, (3) criminal justice involvement, (4) lack of access to health care, and (5) lack of access to transportation. Here, too, we find multiple and intersectional sources of vulnerability of an understudied group.

Following the thread we have spun thus far, we come to "Discrimination Exposure Based on Race, Gender, and Sexual Orientation of Veterans Affairs Health Administration Patients," which also emerges from a feminist, intersectional interpretive framework. Berke and colleagues find that, while relatively few veterans had either seen or experienced harassment at VHA facilities based on racial/ethnic identity, gender, transgender identity, or sexual orientation in the past 12 months, those rates were significantly different among sub-groups. Women experienced significantly greater health care-related discrimination than men, as did racially/ethnically minoritized people relative to non-Hispanic Whites. For observing such discriminatory behavior, significant differences were found between women vs. men, minoritized vs. non-Hispanic White, and lesbian/gay/bisexual vs. heterosexual. Digging deeper than overall rates unearths conditions in need of attention at the VA.

In another vein, this issue includes two papers on e-consults, which seem especially relevant as remote health-related encounters take on a bigger share of the health care space, surging with COVID-19. Joseph and colleagues studied an e-consult program for primary care providers at 12 primary care sites within a public safety-net health system with hospital-based staff and trainee psychiatrists. Many of the consultations, which occurred both via video link and via phone, concerned medication, and the primary care providers widely expressed satisfaction with the service. The findings suggest this intervention facilitates primary care same-day treatment of psychiatry-related conditions in low-resource settings.

A large multi-site federally qualified health center in Texas also implemented an e-consult program with the goal of improving uninsured patient connections with specialists. Comparing the year before the...