Across Europe, coronavirus has ravaged homes for the elderly, raising questions about why the part of society most vulnerable to the disease was overlooked in planning for the pandemic.
Though healthcare systems and policy reactions to the pandemic varied widely, one thing is consistent: in countries where national authorities lost sight of where the virus was spreading, it found its way into care homes and left devastation in its wake.
Roughly half of deaths from the virus across Italy, France, Spain, and Belgium have taken place in nursing homes, according to figures collected by academics at the London School of Economics. In many countries the true figures are only just coming to light, as unlike in Ireland, deaths in care homes were not reported in national figures.
Behind the numbers are individual stories of tragedy. Far from killing people who would have died anyway, the disease stole an average of 13 years of expected life from men, and 11 from women, according to a study of hundreds of victims by University of Glasgow researchers.
Many of their deaths were lonely. Infection risk kept loved ones away or behind panes of glass. The sheer numbers of people who were dying at once overwhelmed staff, and meant people did not always have access to palliative care such as sedatives, to ease their pain as they passed away.
There were errors. In the United Kingdom, patients diagnosed with coronavirus were discharged into nursing homes to free up hospital beds, putting the disease right beside the people most vulnerable to it. In Spain, soldiers sent in to disinfect nursing homes found abandoned elderly people lying dead in their beds.
But across Europe, the toll of the disease was worsened by structural weaknesses in elderly care, which was revealed to be a fragmented and peripheral sector that was overlooked in the initial scramble to procure equipment and prepare hospitals.
From Italy to Sweden, working conditions in care homes made it hard to stop the spread of the disease.
As enclosed spaces where people work in close proximity to the age group most vulnerable to the virus, care homes were always going to be high-risk.
But this was heightened by a rotating roster of staff who often worked more than one job, lacked adequate training and equipment, and had casual contracts that meant they were not paid if they took a sick day.
“Across the European region, long-term care has often been notoriously neglected,” the World Health Organisation’s regional director for Europe, Dr Hans Henri P Kluge, said last month. “The way that such care facilities operate, how residents receive care, is providing pathways for the virus to spread.”
The hardest hit
At the height of Italy’s disaster, local media ran photographs of a chapel in a home for the elderly filled with coffins instead of pews.
Since then, police have raided care facilities across the country as they investigate accusations by employees and grieving family members of mistakes, corner-cutting and reliance on black market labour.
Romolo Reboa is the lawyer representing a group of care home workers who were suspended from their employment after they accused management of preventing them from being able to protect those in their care, including forbidding them to wear face masks in case it frightened residents.
“Families sent their loved ones into long-term care facilities because they thought they would be safe there,” Reboa told The Irish Times. “These were para-hospital institutions. They needed staff who were able to handle the situation . . . In reality, standards were much lower.”
He argues that the novelty of Covid-19 as an illness should not be an excuse for care home management, because they should be experts in infection control as the elderly in their care are vulnerable to many infectious diseases, from seasonal influenza, to nonovirus, to antibiotic resistant bacteria.
In Spain, the government is still collecting national data on how many of the more than 27,500 people lost to the coronavirus lived in care homes. But in the Madrid region, 42 per cent of deaths were in care homes, according to figures from the regional government.
The extent of the disaster in care homes was revealed when soldiers sent in to disinfect them discovered dead elderly people who had been abandoned in their beds.
Sweden and the Netherlands opted for some of the EU's most liberal pandemic responses, choosing not to try to contain the virus but to try to allow it to spread in a controlled manner.
Like in Britain, this policy was justified by a claim that the most vulnerable people in society such as the elderly would be “cocooned” or protected from the disease as it spread.
This did not translate into reality on the ground.
Though family visits to care homes were restricted in the Netherlands, another infection route was left wide open. Workers were advised that they could go to work if they had a cough or cold symptoms, but did not have a fever, according to official advice to care groups seen by The Irish Times.
Availability of protective equipment was limited, and hospitals took priority. By April, Covid-19 cases had been found in 36 per cent of nursing homes, according to the Dutch public health agency.
A harrowing video by a care home worker went viral on Dutch-language social media in April. “All the people here died of corona,” he says as he walks from room to empty room of a care facility. “This whole corridor is dead. Dead.”
Zero hours contracts
Swedish authorities said the vulnerable would be protected as they allowed the virus to spread in the hopes it would increase immunity in the population. This didn’t happen: about half of Swedens 3,680 coronavirus deaths occurred in care homes.
The government was forced to apologise; health minister Lena Hallengren called it "a failure for society as a whole".
Working conditions in care homes were key to their vulnerability, according to Ulf Bjerregaard, who is head of the nursing home division in Sweden's largest union for municipal employees Kommunal. Even in a country of strong social protections, elderly care sticks out for its underpaid and casualised labour force.
About 40 per cent of nursing home workers are thought to be on zero-hours contracts, meaning they often work in several locations, and are not paid if they stay at home when they are sick. They receive little training, and are often let go after they gain experience as employers wish to avoid the legal obligation to offer them a permanent work contract.
“Too few care about elderly care. It’s not important for the politicians. It’s underfunded, it’s low status,” Bjerregaard said. “It’s obvious that we have failed to protect the elderly.”
Professor Devi Sridhar, who is chair of global public health at the University of Edinburgh, believes that mathematical modelling that suggested the vulnerable could be "cocooned" while the strong are exposed to the virus is faulty.
“Shielding doesn’t really work in real life because healthy and vulnerable people interact,” Sridhar told The Irish Times.
“It works well in models, not in complex systems especially in care homes, multi-generational families and those living on their own relying on the community for support.”
Available data is still partial, and the pandemic is far from over. But lessons could be learned from the experiences of countries that did handle the initial outbreaks well, such as Greece.
Greece sticks out in Europe as a country that kept a lid on infections with limited resources, as its public services and healthcare system had been ravaged by long years of crisis and austerity.
An awareness of this vulnerability made the Greek government react early to events in Italy, according to Dr Stella Ladi, assistant professor in public management at Queen Mary University of London and Panteion University, Athens.
Authorities started banning public events in February, a fortnight before Ireland, helping it keep infections to a low enough level to be carefully tracked. Schools and gathering places began to be closed down before the virus spread widely. With one of the oldest populations in the world, the government wanted to take no chances.
“The most significant event was that the measures were taken very early,” Ladi said. “There was a concern that the health system really wouldn’t be able to cope, so the government didn’t want to take any risks”.
When a case was discovered in a home for the elderly in the town of Nea Makri, the institution was put into quarantine. Staff and residents were tested, the ill were moved to hospital, strict hygiene restrictons were put into place and the contacts of those infected were traced.
Greece’s daily death toll never rose above single digits. As the country eases out of lockdown, the number of dead stands at 147.
Case studies: How four European countries fared with care homes
UK - Some discharged from hospital with virus
At the start of the coronavirus epidemic in Britain, Boris Johnson promised the National Health Service (NHS) “anything it needs” to deal with the crisis. By the middle of March, sweeping changes saw non-urgent elective procedures cancelled while new emergency Nightingale hospitals were built, most of which have been largely empty.
But until March 12th, the official guidance on care homes said there was little risk of infection there and it was not until the middle of April that the government published an action plan for the sector. By May 17th, 5889 care homes in England had reported a suspected outbreak of symptomatic or confirmed coronavirus, 38 per cent of the total.
The Office of National Statistics said last week that there were 12,526 registered deaths from coronavirus in care homes between March 2nd and May 1st, more than a third of the total. But the number could be much higher, as the number of people dying in care homes from all causes is three times higher than the average for this time of year over the past three years.
A study from the London School of Economics last week suggested that about 22,000 people in care homes have died directly or indirectly from the pandemic.
Some of those who have died in care homes were discharged from hospital after being infected with coronavirus and returned to homes without testing.
Downing Street said on Monday that the number of such cases has been falling. At the beginning of the epidemic it was not understood within the health system that people with the virus who were asymptomatic could infect others.
Local authorities are responsible for social care in England and access to publicly funded care is determined by needs and means tests, although care homes are mostly run by private organisations. The government last week announced a £600 million Infection Control Fund to help local authorities to cover the cost of measures to halt the spread of coronavirus in care homes.
Throughout the epidemic, care home staff have reported shortages of personal protective equipment (PPE) and until recently often had to travel great distances for testing. The government’s action plan promised to recruit 20,000 new staff for the sector, where low pay and poor working conditions have meant that staff shortages have long been endemic.
The government has asked care homes to restrict staff, many of whom are employed by agencies, to working in only one home if possible.
FRANCE - Staff badly short of protective equipment
Approximately 50 per cent of Covid-19 fatalities in France have been residents of care homes for the elderly, known by the acronym Ehpad (Établissements d’hébergement pour personnes âgées dépendantes).
According to the French public health organisation Santé publique, 28,108 people have died of Covid-19 as of May 17th. Of those, 10,642 died in care homes.
This figure does not include more than 3,300 patients who died after being transferred from care homes to hospitals. When that figure is factored in, care home residents account for about 50 per cent of Covid-19 deaths.
Two-thirds of all Ehpads in France have declared at least one Covid-19 case, and the proportion of elderly victims seems to have grown. Of the 483 deaths registered in France over the 24 hours from May 16th to 17th, 429 perished in care homes, 54 in hospitals.
Of the 28,108 deaths reported on May 17th, 58 per cent were over the age of 60. But other factors have contributed to the high excess mortality rate in French care homes. Medical professional organisations accuse the government of giving priority to hospitals over Ehpads. The shortage of surgical masks and tests, which has been nationwide, intensified the vulnerability of care-home residents.
“The needs of Ehpads were initially under-estimated because official attention was focused solely on what was going on in intensive care units,” Marc Bourquin of the French hospital federation FHF told Le Monde.
Visits to care homes were banned on March 6th, 10 days before the national lockdown started. But medical personnel and caregivers are believed to have transmitted the virus to residents because they lacked personal protective equipment.
The government requisitioned all masks on French territory until March 21st, so care homes could not even purchase them on the market. When distribution of masks finally started, on March 22nd, Ehpads were allotted only two per resident.
The health ministry initially advised care homes to stop testing once three residents of an Ehpad had tested positive for Covid-19. At that point, the entire care home was assumed to be infected. An unknown number of patients are believed to have been needlessly infected because the lack of testing meant positive cases were not isolated.
Several families of deceased care-home residents have filed lawsuits against Ehpads for manslaughter, endangering life and non-assistance to persons in danger.
SPAIN - Residents in care homes found abandoned
In Spain, the handling of care homes and their role in the Covid-19 crisis has been under scrutiny almost since the virus began to spread across the country.
Until recently, Spain was the second-hardest hit country in Europe behind Italy and its current death toll, nearly 28,000, has been attributed in great part to the virus’s presence in homes for the elderly.
However, the leftist government has not yet released figures showing how many care home residents have died, citing the fact that different regional administrations have varying methodologies for collating the information. Europa Press news agency has reported that the national total is “at least” 17,253 – close to two-thirds of total deaths.
A string of care home-related scandals has put the sector firmly under the spotlight. Early on in the crisis, members of the military who had been deployed to disinfect homes found elderly residents in some of them abandoned by staff. There were even reports of the bodies of dead residents having been left in homes in some of these cases.
The state prosecutor is now investigating these as part of a probe into about 150 care homes across Spain, for their alleged failure to respond adequately to the emergency.
In one Madrid home, 17 residents reportedly died from the virus without receiving any medical attention.
Last week, the Las Camelias care home, also in the Madrid region, sparked outrage after members of its staff posted on Facebook photographs of a recent party they had held in the building, complete with suckling pig and flamenco dancing. The event seemed to flout lockdown rules and was seen as distasteful given that about 80 of a total 226 residents of the home have died of coronavirus, according to El País newspaper.
The central government published guidelines for all care homes in early March, asking them to restrict visits and isolate those who appeared to be suffering symptoms. However, as the overall death toll escalated, the government appealed, two weeks later, for regional authorities to ensure those guidelines were being followed.
Spain has both privately- and publicly-run care homes. Pablo Iglesias, leader of the leftist Podemos party and a senior minister in the coalition government, has blamed the increasing involvement of private finance for the sector’s failings in this crisis.
“The privatisation of care homes, handing them over to the corrupt, to vulture funds, has placed our elderly in a position of vulnerability,” he said on Sunday.
GERMANY - Strong focus now on care home sector
Germany has been held up as an example in the Covid-19 pandemic, with early and widespread testing and rapid contact tracing helping to contain the virus’s spread.
A lesser-reported story is how, like many of its neighbours, its first coronavirus scare involved outbreaks in care homes in half a dozen federal states.
About 800,000 Germans live in retirement and nursing homes, most of which are privately run, often by charitable foundations. Until now, no official statistics have been collated on confirmed coronavirus cases and, beyond sporadic news reports, it is difficult to get an overview of the situation.
In late March, a care home in Wolfsburg with 165 residents living with dementia registered 12 deaths within days and 72 Covid-19 infections.
Just before Easter a home in Bonn run by Catholic charity Caritas registered that 70 of its 337 residents, and 38 care staff, had tested positive.
Mid-April saw another outbreak in the western city of Duisburg with three residents dead and 21 out of a total of 104 residents and 15 staff infected. Meanwhile the northern Bavarian city of Würzburg reported 44 deaths in two homes. Public sector broadcaster WDR reported on April 29th the death of 23 people from the virus in Cologne.
AWO, a leading care home operator, has conceded shortages of protective equipment is the greatest challenge in containing the spread of the virus.
On the other hand, statistics from Germany’s Robert Koch Institute, the disease control body, show the largest age-group affected by Covid-19 is not older people but the middle-aged 35-59 age group.
Given it has one of Europe’s oldest populations, Germany has made care homes – both residents and staff – a focus as it adapts its Covid-19 regulations for the second phase of the pandemic.
Last Thursday the Bundestag passed the Infections Protection Act, with a special focus on care homes and hospitals.
The new regime ramps up testing among care home residents and hospitals patients, including people with no symptoms. All tests results – even negative ones – will be logged to help map the virus spread.
Nurses and care workers will be entitled to a €1,000 tax-free bonus, a move to help counter sectors where labour shortages reflect low pay.
After a six-week lockdown, Germany’s 16 federal states have in the last week begun allowing relatives of residents access to care homes.