In a Zoom class at a nonprofit training center for adults, instructor John McIntyre was giving his 17 students a verbal quiz. The class, at the Opportunities Industrialization Center of D.C., or OIC-DC, trains people to be home health aides. It’s 15 weeks long and is held at 6 p.m. because many of the students have jobs or need to look after their children during the day.

“When you’re helping a client who has a stroke, on which side should the home health aide stand — the stronger side or the weaker side?” McIntyre asked.

Twenty-four-year-old Dashia raised her hand. “The stronger side?”

“Hmm. Think about it for a minute.” Dashia did, and changed her answer.

“That’s good! That’s good!” said McIntyre. “We always assist on the weaker side.”

McIntyre praises his students often. He knows they have overcome obstacles to be here. Take Dashia: She was laid off from two restaurant jobs during the pandemic, and she’s now working as a teacher’s aide while taking classes in the evenings to be a home health aide.

“There is such a shortage,” she said. “So I thought, why not take a course?”

But it turned out not to be that easy. Dashia called all seven District of Columbia-approved home health aide training programs for information. She found that they cost between $1,500 to $2,100 and she would also have to pay for transportation, her home health aide certification ($105), first aid and CPR certification ($85), and a background check ($25).

“I definitely don’t have that money,” she said.

And her new job wasn’t likely to make up the cost, either: Home health aide is the fifth lowest-paying among the 25 lowest-paid jobs held disproportionately by people of color, according to a 2020 study of workforce equity in the United States. Other jobs near the bottom include dining room attendant and dishwasher.

The median wage for a home health aide is $24,000 a year, said Matt Sigelman, CEO of labor analytics firm Emsi Burning Glass — about $500 more than for a fast-food cook. “So the notion of taking out a loan and going into debt to get into a job that pays you the same as you would make in a fast-food restaurant is pretty hard to swallow,” he said.

About 16,700 people living in the city are unable to get by without support, and that number is expected to increase every five years, according to the DC Coalition on Long Term Care. Yet, there are just 11,330 certified home health aides and personal care attendants in D.C., according to the Bureau of Labor Statistics 2018 data report. Most are women and people of color, and they make a median hourly wage of $15.04. “Family members will have to pick up much more of the burden,” professor at MIT and author of the book “Who Will Care for Us?” Paul Osterman says. “They’re going to be forced into this unpaid caregiving role with negative consequences for their financial health, their work and also for their mental health. It’s a problem for society.”

The Coalition on Long Term Care, a group that works on senior issues, has consistently criticized the District government for not doing enough to ensure there is an adequate number of direct care workers, for having few high-quality affordable training programs for those workers, and for not having enough oversight of the agencies that hire them once they graduate.

Dashia ultimately got into the one free program in the District, OIC-DC, which is subsidized by the local government and private funds. Otherwise, she said, she wouldn’t have been able to enroll. “My credit is bad so I can’t get a loan, and my family doesn’t have money, either. Everyone is struggling,” she said.

Even though her program is free, Little said, some of the students have to save for months to be able to afford their scrubs, white Crocs, and watches. Advocates say having these students take out loans or borrow from family members is unjust, unfair, and exploitative because it’s unlikely they will be able to pay back that money even after they start working.

Communities across the country are realizing it’s essential to increase the numbers of home health aides.

For years the U.S. relied on immigrants to fill the roles of long-term care workers, said Gail Kohn, coordinator of Age-Friendly DC, an initiative that’s part of the World Health Organization’s ‘Age Friendly Cities’ initiative. But “what we’re seeing recently, at least in the last four years, is a reduction in the number of people who immigrate to this country, which has made it almost impossible to get people into the field.” Almost 40 percent of home health aides are immigrants, according to the Migration Policy Institute, many of them from the Dominican Republic, Mexico, and Jamaica.

Also challenging for recruitment? Being a home health aide can be physically exhausting. Some clients need to be turned every two hours to prevent bedsores; others have to be lifted out of their beds to be bathed. Most private homes are not equipped with devices such as lifts and slings that can help with these tasks.

Thalia, who worked for five years as a home health aide in D.C. before she stopped because of COVID, said she hurt her foot lifting a client but didn’t have health insurance to pay for physical therapy. She had to stop working for months. “You don’t work, you don’t get paid,” she said.

But Thalia considers herself lucky because, with rest, her foot healed. Her neighbor, also a home health aide, injured her back on the job and had to stop working because her agency refused to pay for treatment and she had no insurance, per Thalia.

Aides also have to deal with the irascible – or racist — nature of some elderly clients. Many have dementia or are frustrated that they need assistance. Others “for whatever reason, just don’t like you. They cuss at you and call you names,” said May, who worked as an aide for 11 years and estimated she’s looked after 100 elderly clients. Several home health aides in D.C. had stories of challenges they’ve encountered. One said a client accused her of stealing her glasses and didn’t apologize when she later found them on a bedside table. Another, an immigrant from Nigeria, said clients would complain that her “food smelled” when she was eating lunch. Yet another said a client mocked her accent. Then there is the emotional impact on aides who become close to clients who eventually have to be taken away and institutionalized or die.

Home health aides also feel disrespected by other medical workers, several people said. Some say they are routinely ignored by nurses when they give updates on their clients’ health and aren’t seen as part of the health care team. In general, these positions are “poorly trained, poorly compensated, disrespected and restricted in their duties,” Osterman said.

Osterman argues for expanding the duties of home health aides. In many states, including D.C., they cannot give a client medication or change a bandage without additional training. Expanding the scope of their jobs would help clients with chronic illnesses stay healthier and out of hospitals. “That would also save money, by taking over some of the work from much higher-paid nurses.” Osterman said those savings could go toward better salaries.

Aides are also at the mercy of their staffing agencies for assignments, and receive little support. May says her training included working with patients who had mild dementia. But one of the first clients she was assigned to had schizophrenia and was bipolar. She says she was always fearful.

“I had no training and they just put me there. That was very scary for me.” She says her agency supervisor told her to carry Mace. “I had to be on guard whether he was going to do anything or not cooperate or not take his medication. It was just me and him in there.”

The disrespect affected May’s decision to quit. “No one believes this is a real job,” May said. She’d like the title “home health aide” to be “changed to something with ‘medical’ in it,” in the hope of getting more respect. “We do a lot of work, and we’re not recognized for it.”

When she graduates from her home health aide class, Dashia said, she wants to continue studying and move up in the health care field. She hopes she can one day earn a degree. “I want to do something that’s not just for the moment,” she said.

Sigelman said home health aides are just a few training courses away from gaining additional skills to move up and into jobs that pay much better and provide benefits, such as certified nursing assistant ($31,000), medical assistant ($36,000), health information technician ($44,000) or licensed practical nurse ($49,000). None of these professions requires a college degree. But he said upward mobility doesn’t happen by accident. “It requires that we help people make that jump. And unfortunately, that doesn’t happen too often.”

If there isn’t this “supported progression” for home health aides, they may move out of health care altogether and look for different occupations, said Johan Uvin, who was acting assistant secretary for the Office of Career, Technical and Adult Education under President Barack Obama.

Uvin said there are encouraging signs of innovation. Some training institutions offer clear pathways from, say, home health aide to certified nursing assistant to licensed practical nurse to registered nurse. “It’s a very worker-centered way of thinking about it,” he said.

Uvin said this moment presents an opportunity to change things not just at the grass roots, but also at the policy level.

For example, students could be given access to federal financial aid such as Pell grants for short-term career training programs. Other inducements for training programs could create more comprehensive pathways for their home health aide students. “There’s a lot we can do with incentives through policy,” Uvin said.

He said the current system, requiring home health aides to go through a training program and get certified in order to get a job that doesn’t even pay “survival” wages, will just “magnify the inequities that already exist.”

“And that’s just unjust.”

This story was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the higher education newsletter.

This story was supported by the Higher Education Media Fellowship at the Institute for Citizens & Scholars. The Fellowship supports new reporting into issues related to postsecondary career and technical education.