Briana Mezuk, Ph.D., is an associate professor in the Department of Epidemiology at the University of Michigan in Ann Arbor, as well as the co-director of the University’s Center for Social Epidemiology and Population Health. In this opinion piece, she asks us to consider the impact that the November election will have on the health of older adults in the United States, especially in light of the current pandemic.
In about a month, this country will vote on 11 governors, 35 U.S. Senate seats, all 435 U.S. House of Representative seats, and, of course, our President and Vice President.
These elections, as with all elections, will have consequences for healthcare policy and regulation. There is undoubtedly truth in the statement that “All politics is local,” but we are living through the limitations of that approach when it comes to political actors managing the spread of an infectious disease that has no sense of municipality, county, or state lines.
The COVID-19 pandemic may be the newest healthcare challenge facing our nation, but it is following many of the same well-trodden patterns that characterize our more familiar public health problems: namely, that the burden of disease is unequally distributed, such that those who have less — be it less financial security, less personal space, less robust health status, or less autonomy — are more affected.
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Early stories about the toll of the pandemic called it “the great equalizer,” but that narrative has begun to give way for the more accurate analogy that we are “in the same storm, but not in the same boat.”
The veracity of this statement is clear when we consider the impact of COVID-19 on older adults. About one-third of the documented deaths from the coronavirus have occurred among people living in residential care settings, such as nursing homes and independent or assisted living facilities.
One of the first documented outbreaks of COVID-19 in the U.S. was in a long-term care facility in Washington state, where the virus infected more than 167 residents, staff, and visitors, and killed 34 people in the short span between February 27 and March 18, 2020.
Many of these deaths occurred among people with several “underlying health issues,” which contribute to the risk of mortality from COVID-19. Emphasizing this helps us manage our collective anxiety about the virus by justifying it as: “They were already sick, so is it really that surprising that they died?”
But that is a self-serving narrative; one that “feels right” because of an “-ism” — ageism — that last socially acceptable form of discrimination that permeates many of our conversations about the pandemic. A counter-narrative to this would be that these deaths occurred among people who had families, children, and friends, as well as lifetimes of knowledge and experience that is now lost.
Beyond these risks of life and limb, COVID-19 increasingly poses risks to our mental health, particularly that of older adults living in residential care settings. There, they have experienced “lockdowns” that make the “stay-at-home” orders that the rest of our population experienced look like a day at the beach.
Residents of many facilities remained confined to their rooms for weeks at a time, and visitors (i.e., their spouses, children, and other kin) were prohibited from entering. In some cases, this meant that loved ones could not be present when their parent or spouse died.
We need to name the experience that older adults and the staff who work in residential care settings have experienced over the past 9 months: They have experienced a slow moving, but nevertheless enormous, trauma.
They have stood witness to the deaths of their neighbors, friends, clients, and coworkers; their risk status has meant that loved ones have been unable to physically comfort them as they grieve; and they have been living in a heightened state of vigilance over their own health and safety with which few of us can empathize.
The psychological sequelae of such traumas are well-documented. Feelings of depression, anxiety, insomnia, irritability, and aggression are common among people who have experienced trauma.
However, contrary to popular belief about what it is like to be in the seventh or eighth decade of life, such feelings are not the norm for older adults. In fact, feelings of depression, anxiety, and irritability decline substantially with age after the mid-30s, and older adults are much more likely to report positive affect than their youthful counterparts.
Time will tell whether the perspective and “wisdom” that come with age will be sufficient to protect older adults from the negative psychological consequences of living through COVID-19. But one of the lessons we must learn from their experience is that it did not have to be this way.
In their outbreak investigation of the Washington state long-term care facility, the Centers for Disease Control and Prevention (CDC) noted “factors that were likely to have contributed to the vulnerability of these facilities, including:
- staff who had worked while symptomatic;
- staff who worked in more than one facility;
- inadequate familiarity with and adherence to PPE recommendations;
- challenges to implementing proper infection control practices, including inadequate supplies of PPE and other items (e.g., alcohol-based hand sanitizer);
- delayed recognition of cases because of a low index of suspicion;
- limited availability of testing;
- and difficulty identifying persons with COVID-19 on the basis of signs and symptoms alone.”
It is important to recognize the euphemisms in this report.
Staff working while symptomatic is a direct result of workplace policies — such as unpaid sick leave — that do not recognize the institution’s responsibility to prevent infectious disease, COVID-19 or otherwise, from entering facilities through staff.
Staff working at more than one facility is a direct result of the notoriously low pay of direct care staff who work at residential care facilities — a healthcare sector that has extraordinarily high profit margins.
“Inadequate familiarity” with infection control practices is a direct result of incompetent institutional leadership that does not prioritize effective training of staff on best practices for protecting their health and the health of their residents.
That is to say that many, if not most, of these deaths were preventable. I don’t mean that the older adults living in residential care had promised that they would never die (Team America!), but rather that they would not have died when they did.
People often discount the mental health and well-being of older adults because of ageism, but we need to hold residential care institutions accountable for their end of the bargain. After all, they agreed to support our loved ones during their last years and to provide a place not only of safety but of comfort and meaning.
However, while COVID-19 caused some residential care facilities to function as de facto prisons, it caused others to rise to the occasion by protecting the health of their staff and residents and hiring specialists to support their residents through this crisis.
There are known political tools and regulatory mandates that, if implemented with fidelity, would have saved lives — for both older adults living in residential care and the people whose job it is to care for them.
Paid sick leave, higher wages for staff, and higher fines for infection violations — these are readily available tools for incentivizing the behavior that older adults and their families want — that they deserve — from residential long-term care.
Those tools and mandates can still be implemented, and they can still save lives. And we should remember this when we are voting this November.
As we continue to live with COVID-19, which will be with us for the foreseeable future, we need to identify leaders who will help us navigate this disaster and its collateral damage.
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