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Canada’s “national shame”: Covid-19 in nursing homes
https://www.vox.com/future-perfect/2020/7/7/21300521/canada-covid-19-nursing-homes-long-term-care
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Nursing homes account for 81 percent of Covid-19 deaths in the country. How did this happen?
Canada’s response to the coronavirus pandemic has generally been viewed as a success, with experts pointing to its political leadership and universal health care system as factors.
But there has been one glaring failure in Canada’s fight against the pandemic: its inability to protect the health of its senior citizens in nursing homes and long-term care facilities.
The situation for these seniors is so dire that the police — and even the military — have been called in to investigate why so many are dying.
In Quebec, some residents have been left for days in soiled diapers, going hungry and thirsty, and 31 residents were found dead at one home in less than a month, leading to accusations of gross negligence. In Ontario, the military found shocking conditions in five homes: cockroaches and rotten food, blatant disregard for infection control measures, and treatment of residents that was deemed “borderline abusive, if not abusive.”
“It’s a national shame,” said Nathan Stall, a geriatrician at Toronto’s Sinai Health System. “I don’t think we’ve done a good job at all in Canada.”
A whopping 81 percent of the country’s coronavirus deaths are linked to nursing homes and long-term care facilities. That means roughly 7,050 out of 8,700 deaths to date have been among residents and workers in these facilities.
In terms of raw numbers, that may not seem like very much. (For comparison, more than 40,000 US coronavirus deaths have been linked to nursing homes.) And, to be clear, Canada is hardly alone in watching tragedy unfold in these facilities. The US and Europe have seen startling numbers of fatalities among nursing home staffers and residents.
But 81 percent is a staggering statistic, especially for Canada, a country that prides itself on its progressive health policies. And it’s higher than the rate in any other country for which we have good data. In European countries, roughly 50 percent of coronavirus deaths are linked to these facilities. In the US, it’s 40 percent.
Experts say a number of factors are probably involved in Canada’s collapse on the nursing home front, like the fact that Canada has done well at controlling community spread outside these facilities (making nursing home deaths account for a greater share of overall deaths) and that residents in Canadian homes tend to be older and frailer than those in US homes (and thus more vulnerable to severe cases of Covid-19). But they say the high death rate in the homes is due, in large part, to egregious problems with the homes themselves.
“I think we have serious issues with long-term care,” said Vivian Stamatopoulos, a professor at Ontario Tech University who specializes in family caregiving. Experts have been warning political leaders about this for years, but, she said, “they’ve all been playing the game of pass the long-term care hot potato.”
Furious over how their elders are being treated, some Canadians have started petitions, protests, lawsuits, and even hunger strikes outside the homes. They say the government’s failure to respond reveals a deeper failure to care about seniors and people with disabilities, and to make that care concrete by sending facilities what they urgently need: more tests, more personal protective equipment (PPE), and more funding to pay staff members so they don’t have to work multiple jobs at different facilities.
Prime Minister Justin Trudeau has acknowledged that the situation in the facilities is “deeply disturbing.” He’s sent hundreds of military troops to help feed and care for the seniors in certain homes, where burnout and fear have prompted some staff members to flee their charges. But to some extent, Trudeau’s hands are tied because the facilities fall under provincial jurisdiction.
That leaves families terrified for their loved ones. They’re asking: Why have things gone so terribly wrong? How could this happen in Canada?
Canada’s crisis was a long time in the making
The first thing to understand is that Canada’s universal health care system does not cover nursing homes and long-term care facilities. That means these institutions are not insured by the federal system. Different provinces offer different levels of cost coverage, and even within a given province, you’ll find that some homes are publicly run, others are run by nonprofits, and still others are run by for-profit entities.
“This is the main problem — they don’t fall under the Canada Health Act,” said Stamatopoulos, adding that the same is not true of hospitals. “That’s why you see that the hospitals did so well. They had the resources.”
From the standpoint of someone in the US, where more than 132,000 people have died of Covid-19, Canada may seem to be doing well overall: The death toll there is around 8,700. Per capita, Canada’s coronavirus death rate is roughly half that of America’s. It’s clear that the northern neighbor has been doing better at keeping case numbers down, partly because it’s giving safer advice on easing social distancing.
Which makes the dire situation in nursing homes stand out even more. Longstanding problems with Canada’s nursing homes have clearly fueled the tragic situation unfolding there.
These homes are chronically understaffed. They tend to hire part-time workers, underpay them, and not offer them sick leave benefits. That means the workers have to take multiple jobs at different facilities, potentially spreading the virus between them. Many are immigrants or asylum seekers, and they fear putting their precarious employment at risk by, say, taking a sick day when they need it. (These problems aren’t unique to Canada, but as in other countries, they’ve been thrown into stark relief by the pandemic.)
A lot of Canadian homes also have poor infrastructure, built to the outdated design standards of the 1970s. Residents often live four to a room, share a bathroom, and congregate in crowded common spaces. That makes it very difficult to isolate those who get sick.
These problems are even worse in Canada’s for-profit nursing homes. Research shows that these private facilities provide inferior care for seniors compared to the public facilities, in large part because they hire fewer staff members and put fewer resources into upgrading or redesigning their buildings. The for-profit model incentivizes cost-cutting. (Similarly problematic profit motives and poor living conditions persist in US nursing homes, too.)
Canadian experts have been raising the alarm about these issues for more than a decade. So why haven’t they been addressed?
“Frankly, overall, it really reflects ageism in society. We choose not to invest in frail older adults,” Stall said. He added that early on in the pandemic, the public imagination latched onto stories of relatively young people on ventilators in hospitals. The hospitals and their staff got resources, free food, nightly applause. Homes for older people didn’t get the same attention.
“Nursing homes are not something we’re proud of societally. There’s a lot of shame around even having someone in a nursing home,” Stall said.
Stamatopoulos noted there are other forces at play, too. “I’d say it’s a trifecta of ageism, racism, and sexism,” she said. “When you look at this industry, it’s majority female older residents being cared for by majority racialized women.”
Ronnie Cahana, a 66-year-old rabbi who lives with paralysis at the Maimonides Geriatric Centre in Montreal, recently wrote a letter to Quebec’s premier. “I am not a statistic. I am a fully sentient, confident human being, who needs to have my humanity honored,” he wrote, adding that the premier should help the workers who take care of people like him. “Many of them are immigrants, newly beginning their lives in Quebec. … Please give them all the resources they require. Listen to their voices.”
How to make nursing homes safer — in Canada and beyond
If you want to keep nursing homes from becoming coronavirus hot spots, look to the strategies that have proven effective elsewhere. For months now, Canadian public health experts and advocates have been begging leaders to do just that.
All residents and workers in nursing homes should be tested regularly, whether they show symptoms or not. Anyone who gets sick should be isolated in a separate part of the building or taken to the hospital. Workers should be given adequate PPE, and universal masking among them should be mandatory. Working at multiple homes during the pandemic should be disallowed.
“Look at South Korea. They’ve had no deaths in long-term care because they treated it like SARS right from the get-go,” Stamatopoulos said. “They did aggressive testing. They were strict in terms of quarantining any infected residents and were quick to move them to hospitals. We’ve done the opposite.” Earlier in the pandemic, some Canadian hospitals sent recovering Covid-19 patients back to their nursing homes too soon; they inadvertently infected others.
“And look at New York state,” Stamatopoulos continued. “Gov. Cuomo signed an executive order on May 10 requiring all staff and residents to be tested twice a week. That aggressive testing helped halt the outbreaks in the homes.” Quebec and Ontario have yet to do this.
British Columbia, a Canadian standout at preventing deaths in nursing homes, adopted several wise measures early on. Way back on March 27, the western province made it illegal to work in more than one home — and topped up workers’ wages so they wouldn’t have to. It gave them full-time jobs and sick leave benefits.
It’s clear that so long as long-term care falls under provincial jurisdiction, nursing home residents will be better off in some provinces than in others. So some Canadian experts, including Stamatopoulos, are arguing that these facilities should be nationalized under the Canada Health Act. Others are not sure that’s the answer; Stall thinks it may make sense to target only for-profit homes, compelling them to improve their poor infrastructure. In the long term, any homes that do not meet modern standards should be redesigned.
Another lesson for the long term comes from Hong Kong, which has managed to totally avoid deaths in its nursing homes. Even before the coronavirus came along, all homes had a trained infection controller who put precautions in place to prevent the spread of infections. (US homes saw a similar system enacted under President Obama, but President Trump has proposed that it be rolled back.) Four times a year, Hong Kong’s homes underwent pandemic preparedness drills so that if an outbreak occurred, they’d be ready with best practices. It did, and they were.
Preparedness clearly saves lives. Hopefully, Canada and other countries will learn that lesson going forward so that no more lives are needlessly lost.
As Cahana, the resident in the Montreal home, said, “Each of us is crying to be heard. We say: More life! Please! We are not afraid of the future. We are afraid that society is forgetting us.”
3 moral virtues necessary for an ethical pandemic response and reopening
The health and economic impacts of the coronavirus pandemic are not equally felt. From the United States to Brazil and the United Kingdom, low-wage workers are suffering more than others and communities of color are most vulnerable to the virus.
Despite the disparities, countries are reopening without a plan to redress these unequal harms and protect the broader community going forward. Our ethics research examines the potential for using virtues as a guide for a more moral coronavirus response.
Virtues are applied morals – actions that promote individual and collective well-being. Examples include generosity, compassion, honesty, solidarity, fortitude, justice and patience. While often embedded in religion, virtues are ultimately a secular concept. Because of their broad, longstanding relevance to human societies, these values tend to be held across cultures.
We propose three core virtues to guide policymakers in easing out of coronavirus crisis mode in ways that achieve a better new normal: compassion, solidarity and justice.
1. Compassion
Compassion is a core virtue of all the world’s major religions and a bedrock moral principle in professions like health care and social work. The distinguishing characteristic of compassion is “shared suffering:” Compassionate people and policies recognize suffering and take actions to alleviate it.
As the French philosopher André Comte-Sponville said, compassion “means that one refuses to regard any suffering as a matter of indifference or any living being as a thing.”
Individual acts of compassion abound in the coronavirus crisis, like frontline health care professionals and neighbors who deliver food, among other examples.
Some pandemic-era policies also reflect compassion, such as regulations preventing evictions and expanding unemployment benefits and giving food aid to poor familes.
A compassion-guided reopening aimed at preventing or reducing human suffering would require governments to continually monitor and alleviate the pain of their people. That includes addressing new forms of suffering that arise as circumstances change.
2. Solidarity
In a global pandemic, the actions people do or don’t take affect the health of others worldwide. Such shared emergencies require solidarity, which recognizes both the inherent dignity of each individual person and the interdependence of all people. As United Nations officials have emphasized, “we are all in this together.”
Public health measures like stay-at-home orders, social distancing and wearing masks reflect solidarity. While compliance in the United States has not been universal, data indicate broad approval for these measures. A new study found that 80% of Americans nationwide support staying home and social distancing and 74% support using face coverings in public.
To achieve these acts of solidarity, the leaders most praised in their countries and abroad – from U.S. National Institutes of Health director Dr. Anthony Fauci to New Zealand prime minister Jacinda Ardern – have relied primarily on moral persuasion, not threats of punishment.
By delivering clear information, giving simple and repeated behavioral guidance, and setting a good example, they’ve helped convince millions to take personal responsibility for protecting their community.
3. Justice
Justice focuses on the fair distribution of resources and the social structures that enable what the Dutch philosopher Patrick Loobuyck has called a “condition of equality.”
Justice-oriented policies are necessary for a moral reopening because of the pandemic’s disproportionate health and economic impacts. The evidence clearly shows that communities of color, low-income populations, people in nursing homes and those on the margins of society, such as homeless people and undocumented immigrants, are hardest hit.
Justice-oriented policies would aim for equitable balancing of necessary pandemic resources. That means directing testing and health equipment toward vulnerable communities – as identified by COVID-19 tracking data and risk factors like housing density and poverty – and ensuring free, widespread vaccine distribution when it becomes available.
In the U.S., economic justice will also require aggressively investing in minority-run businesses and poorer areas to guard against further harm to owners, employees and neighborhoods.
Similarly, all American school children have lost critical classroom hours, but lower-income children have been disproportionately damaged by remote learning in part due to the digital divide and loss of free lunch programs. Justice would demand channeling additional resources to the students and schools that need them most.
A moral reopening
Using virtues to guide social policies is an old idea. It dates back at least to the Greek thinker Aristotle.
New Zealand is a good example of virtuous pandemic policymaking, even considering its advantages in having wealth, low density and no land borders. Its coronavirus response included not only aggressive public health measures but also a well articulated message of being united in the COVID-19 fight and recurring government payments so workers did not have to risk their health for their job.
Note that it isn’t enough to apply just one virtue in a crisis of this magnitude. Policies built on compassion, solidarity and justice should be deployed in combination.
A compassionate post-pandemic response that does not address underlying inequalities, for example, ignores certain communities’ specific needs. Meanwhile, tackling specific injustices without engaging everyone in efforts like mask-wearing endangers the public health.
Bolstered by scientific evidence, virtue ethics can help nations reopen not just economically but morally, too.
Providers show support amid unrest: #WhiteCoatsForBlackLives
Dive Brief:
- The American Hospital Association on Monday condemned what they called the “senseless killing of an unarmed black man in Minneapolis,” referring to George Floyd, who died more than a week ago after a police officer held his knee on Floyd’s neck for more than eight minutes. AHA said the group’s vision is a “society of healthy communities, where ALL individuals reach their highest potential for health.”
- Medical societies, providers and other healthcare organizations weighed in to support peaceful protests, especially as the COVID-19 pandemic shines a light on racial inequities in access to healthcare and job security in America.
- Health officials also expressed worry that the protest gatherings could further spread of the novel coronavirus. Minnesota Gov. Tim Walz said hospitals in the state could be overwhelmed. And some COVID-19 testing sites have been shut down for safety reasons, further exacerbating concerns.
Dive Insight:
Since protests and occasionally violent police confrontations in recent days were sparked by Floyd’s death, providers have taken to social media with notes of support and pictures of themselves taking a knee in their scrubs under the hashtag #WhiteCoatsForBlackLives.
The American Medical Association responded to ongoing unrest Friday, saying the harm of police violence is “elevated amidst the remarkable stress people are facing amidst the COVID-19 pandemic.”
Board Chair Jesse Ehrenfeld and Patrice Harris, AMA’s first African American woman to be president, continued: “This violence not only contributes to the distrust of law enforcement by marginalized communities but distrust in the larger structure of government including for our critically important public health infrastructure. The disparate racial impact of police violence against Black and Brown people and their communities is insidiously viral-like in its frequency, and also deeply demoralizing, irrespective of race/ethnicity, age, LGBTQ or gender.”
Other organizations weighed in, including CommonSpirit Health, the American Psychiatric Association, the American College of Physicians and several medical colleges.
The nascent research and data from the pandemic in the U.S. have shown people of color are more likely to die from COVID-19 than white people. The reasons behind that are myriad and complex, but many can be traced back to systemic inequality in social services and the healthcare system.
Payers, providers and other healthcare organizations have attempted to address these issues through programs targeting social determinants of health like stable housing, food security and access to transportation.
But despite these efforts over several years to recognize and document the disparities, they have persisted and in some cases widened, Samantha Artiga, director of the Disparities Policy Project at the Kaiser Family Foundation, noted in a blog post Monday.
“Health disparities, including disparities related to COVID-19, are symptoms of broader underlying social and economic inequities that reflect structural and systemic barriers and biases across sectors,” she wrote.
Providers have waded into political issues affecting them before, including gun violence. Several organizations also objected to the Trump administration’s decision to cut ties with the World Health Organization in the midst of the pandemic.
The American Public Health Association in late 2018 called law enforcement violence a public health issue.
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Sign of the Week
In front of White House, nurses read names of colleagues killed by coronavirus
The names came from all over the country — New York and Alabama, Puerto Rico and Nevada, California and Michigan, Florida and Maryland, New Jersey and the District.
A man in blue scrubs stood behind Jones as she read, holding a metallic gold sign painted with the message: “20 seconds won’t scrub ‘hero’ blood off your hands.”
“Let us remember and honor the ultimate sacrifice these nurses paid,” Jones said. “We commit ourselves to fight like hell for the living.”
The protest stood in stark contrast to demonstrations in recent days in some parts of the country in which protesters have demanded the reopening of nonessential businesses. Nurses have been spotted at those gatherings, too, standing arms crossed, in opposition to demonstrators, many of whom are unmasked and milling in crowds.
More than 9,000 health-care workers in the United States have tested positive for the novel coronavirus, according to figures from the Centers for Disease Control and Prevention. Those numbers are believed to be an undercount of infections due to a lack of tests in many areas.
The nurses said Tuesday that they wanted to bring their demands for more personal protective equipment directly to President Trump’s doorstep.
Health-care providers in hospitals, clinics, nursing homes, assisted-living facilities and rehabilitation centers have for weeks asked lawmakers and government agencies for more protective equipment to shield themselves and their vulnerable patients from the spread of covid-19.
National Nurses United last month petitioned the Occupational Safety and Health Administration to institute an emergency safety standard that would provide nurses with more protective gear, including N95 respirator masks, face shields, gowns, gloves and shoe coverings.
Health-care workers, governors and other officials have for weeks demanded that Trump enforce the Defense Production Act to order mass production of those materials. Many have also petitioned Congress to mandate Trump use his authority to help boost the production of such gear.
Last week, a protest in the shadow of the Capitol displayed the faces of health-care workers demanding better protection on 1,000 signs. The sign represented protesters that organizers said would not have been safe if gathered together on the Capitol lawn.
Standing Up to a Tidal Wave of Ignorance, Fear and Abuse
Today I stood with some of my fellow nurses and faced a tidal wave of ignorance, fear, and abuse.
I was mocked. I was called more names than I can remember. I was told I was ignorant, unintelligent, and compassionless. I was accused of being a fake nurse, a paid protester, a fraud. I was told I was nothing. I had cigarette smoke blown in my face. I was sexually harassed. A few times, I was surrounded on all sides by multiple people yelling at me.
Desperation and fear bring out the worst in people. I will admit, I cried a bit. How could I not in the face of so much hate?
But I when I did, I was crying for my fellow healthcare workers on the front lines, who are working their asses off fighting this illness, who are being put at worse risk because of the lack of essential protective equipment in this country. I cried for those who have left their families behind to go help where the situation is most dire. I cried for those who have died and will continue to die, after working their hardest to help those who needed them.
I cried for every protester who doesn’t know how they are going to make ends meet, that are afraid for their businesses, their jobs, their homes, and their lives. I cried for every American who has received less than adequate help from the government, who felt like this is the only way for them to get the resources they need, and who have been failed by our president who has not implemented the measures required to help and protect our most vulnerable people.
I cried for every person at this protest that will inevitably get sick, and increase the spread in our state when we had been doing a pretty good job of flattening the curve and delaying the spread of covid-19 in Arizona. I cried for every person who will be infected by those that contracted the disease today.
But more important than the few tears I shed today, was that I stood strong for what is right.
I stood for using science, not feelings, to make important decisions in a pandemic. I stood for the healthcare workers who are going to keep working our hardest to help heal the sick, whether they appreciate it or not. I stood for those who couldn’t. I stood for the lives we have lost, many unnecessarily, to this virus. I stood strong and looked every protester fighting to open Arizona in the eye, so they would have to stare into the face of some of the individuals they are hurting with their ignorance. My hands cramped up from standing in this position so long, but I kept standing until everything died down.
And I will keep standing.
Health Care Workers Stand Up To People Protesting Stay-At-Home Orders
https://nowthisnews.com/news/health-care-workers-stand-up-to-people-protesting-stay-at-home-orders
Remarkable scene at 12th and Grant, where two healthcare workers from a Denver-area hospital — they declined to say which or give their names — are standing in the crosswalk during red lights as a “reminder,” they say, of why shutdown measures are in place.
Two health care workers blocked a parade of protesters in Denver, Colorado on Sunday, who were storming the capitol to protest the state’s stay-at-home order.
Powerful images and videos of the standoff were widely shared on social media of the two unidentified people wearing scrubs and N95 masks, standing in a crosswalk blocking protesters’ vehicles. The two were identified as health care workers by photographers on the scene.
One video shared by Twitter user Marc Zenn, captured cars lined up and beeping their horns at the two medical workers, with a woman hanging out of her vehicle’s window shouting “Go to China if you want communism. Go to China,” and “You get to go to work, why can’t we?”
They say they’ve been treating COVID patients for weeks. Today most of the people driving by have been “very aggressive,” they say. I’ve been standing here for a few minutes and already seen two people get in their faces.
Hundreds of people showed up on foot and in their vehicles for two separate protests in Colorado’s capitol on Sunday. The protests were reportedly planned by ReOpen Colorado and “various Libertarian parties,” according to a local Denver news outlet. People attending the march were shown carrying American flags, “Don’t Tread on Me” flags, and signs about reopening businesses and schools.
“Coloradans have a first amendment right to protest and to free speech, and the Governor hopes that they are using social distancing and staying safe,” Colorado Gov. Jared Polis’ office said in a statement. “No one wants to reopen Colorado businesses and lift these restrictions more than the Governor, but in order to do that, Coloradans have to stay home as much as possible during this critical period, wear masks and wash their hands regularly to slow the spread of this deadly virus.”
As of Monday morning, Colorado has more than 9,700 cases of COVID-19, leading to at least 420 deaths, according to the Johns Hopkins coronavirus tracker. The state of Colorado is set to continue its stay-at-home order until at least April 26, to slow the transmission of the virus.
Colorado isn’t the only state where protesters are demonstrating against their government’s stay-at-home orders—Several other states held protests over the weekend including Utah, Idaho, and Washington state. Last week, parts of Michigan, New York, Ohio, Virginia, North Carolina, and others also saw a wave of demonstrators.
President Trump encouraged the protesters last week during his Friday press briefing and in tweets which said to “liberate” multiple states holding protests.
In a Politico poll, 81% of Americans agreed we “should continue to social distance for as long as is needed to curb the spread of coronavirus, even if it means continued damage to the economy.” An NBC News poll found that 60% of responders agreed with keeping at-home restrictions.
HENRY KOTULA 