Canada's Shameful Neglect of the Aged/Infirm During COVID-19 Pandemic

"It is hair-raising. We are expecting a second wave and long-term care homes are not ready."
"Overall, it is a completely unacceptable level and quality of care."
Natalie Mehra, executive director, Ontario Health Coalition

"Historically, the federal government has failed to support this sector [nursing and long-term care homes] ... It is imperative they help the sector by providing access to existing federal infrastructure dollars."
"These are simple and readily available solutions [allowing nursing homes access to funds through the national housing strategy] that could have been and can still be implemented quickly to support provinces and operators in modernizing long-term care homes."
"Seniors and their families do not care about who is, strictly speaking, responsible for what parts of senior-care delivery. The arguments that the federal government distributes funds and provinces provide programs might have been a thoughtful argument in the past, in the '80s and '90s, but the demographics today are completely different."
"The federal government cannot ignore the aging crisis any longer."
Jody Hall, association chair, The Canadian Association for Long Term Care

Lack of  support for long-term care homes contributed to conditions leading to widespread COVID-19 outbreaks and deaths in Canadian nursing homes. It was soon discovered with the onset of the first wave of global infections due to SARS-CoV-2, the extent of the fragility of the system of long-term care which became uniquely vulnerable to COVID. Already-vulnerable patients and a new coronavirus took its deadly toll. That was readily seen when it became clear that overall 81 percent of COVID-19 deaths in Canada occurred in long-term care homes.

In comparison, the United States, a developmentally comparable country, but with an immense case load of COVID, saw 31 percent of total deaths from their long-term care homes. In Australia, 28 percent accounted for their total overall death rate, while Spain suffered a 66 percent loss of life in their long-term care homes; all other countries vastly below the number that Canada realized in senior deaths.

Some of the reasons that Canada had such an overwhelming death rate in long-term homes is that the homes in Canada are frequently older, featuring shared bedrooms, bathrooms and dining rooms. Containing COVID-19 became an insuperable challenge in the pandemic's early days when knowledge of its infection rate was sparse, much less its capacity to spread though asymptomatic people.

The Royal Society of Canada early in July released a report on the state of long-term care in Canada wherein it accused the country of failing to protect vulnerable elders. The pandemic represented a "shock wave", exposing many deficiencies of long standing in the system, so that while causes of the systemic failure may be complex, they are also rooted in a situation the report authors spoke of as "systemic and deeply institutionalized implicit attitudes about age and gender".

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Across Ontario and Quebec and in other provinces, some homes experienced hundreds of infections, resulting in dozens of deaths of residents, along with the deaths of three personal support workers and illness of many more. Workers had been instructed they may only work at one home at a time, a move meant to reduce the opportunistic spread of infections, which has also exacerbated staff shortages. Many workers attended at multiple care homes since few institutions offer full-time hours.

An extreme shortage of staff at long-term care homes has left the situation in a more parlous state than it was before the pandemic, despite governments at every level professing their shock at the health mayhem that occurred in the first wave, pledging to pull out all the stops to make the homes safer for their residents. Front-line workers began receiving a modest pay bump, now reaching a deadline in an industry that pays their workers very poorly and fails to give them sufficient training.

The Ontario Health Coalition released a survey indicating that 95 percent  of long-term care staff who responded, reported the home they worked at was short-staffed and 63 percent that staffing levels had become more serious than before COVID arrived,k while 28 percent indicated staffing levels remained static. Disturbingly staff also reported residents regularly miss baths and showers because of staff shortages. They spoke of non-existent time to provide residents with emotional support.

Describing stress and limited time frames, they spoke of missing brushing teeth for residents, shaving and caring for their nails, along with sufficient time lacking for the critical issues such as feeding and hydrating residents properly; to reposition them to avoid bed sores, or to take them to the bathroom. The result has been more falls among residents. Personal support workers who constitute the bulk of long-term care staff are in a shortage position at many homes.

But the list of negatives don't end quite there. Shortages also exist of nurses, housekeepers, dietitians and those who do the laundry, engage in activities and rehabilitation. "I don't understand how this is allowed to happen", said a shocked long-time personal support worker, reviewing the findings of the Ontario Health Coalition survey; positively "repulsive".

A file photo from an Ontario long-term care home. Brian Thompson / Postmedia

Sanctimony over Sacred Duty

“As this COVID-19 outbreak unfolds in coming months, our government will aim to support Canadians and keep them protected. We’ve based our response on input from our world-class health professionals and authorities. We know what the science is telling us. The evidence is clear. The elderly are our greatest risk. We’ve seen the experience in Italy and Spain. We know what happened in China. In Washington State. The first long-term care death in British Columbia occurred March 8."
"The signals are clear. The most vulnerable Canadians are in long-term care institutions."
"Today our government is allocating $20 billion to deploy as many physical and human resources as possible to stop this pandemic from reaching our most vulnerable population. If you are in a long-term care home, or are related to someone who is, rest assured. Our top priority is to get you the help you need."
Prime Minister Justin Trudeau, March statement of assurance

"What’s special about COVID-19 is the asymptomatic transmission. The whole strategy of looking for fever and looking for symptoms didn’t work."

"By the time we found somebody with symptoms, and then tested everybody in the home, you would find 40 or 50 residents already positive."

Long-Term Care Home executive

Words are important. If the words are strung together well and they approach a situation while appealing to those who are or will be deleteriously affected, they give reassurance. They shine a light of approval on whoever utters those words, the promise that the problem has been analyzed and authorities are prepared to undertake a solution that will meet the challenges of an all-consuming worry over the projected plight of the most vulnerable within society.

Those words were uttered, the assurance that government is aware and fully prepared to launch a program that would create the needed solution to a viral pathogen threatening the lives of Canada's elderly and health-impaired. After all, before the SARS-CoV-2 invasion hit Canada, there were examples out of Wuhan, China, where the novel coronavirus first emerged before spreading to Europe and onward to radiate over the entire globe with mixed results, none of them good.

Reports being received of the desperate carnage wreaked on institutions housing the elderly and health-compromised, due warning that this disease strikes those least able to ward off its destructive impact due to immune-compromised conditions linked to old age and/or to chronic and/or dread disease onset. Nothing quite so much focuses the mind as watching a tornado of disaster wreak hell elsewhere while it steadily advances toward you, waiting with bated breath.

75 per cent of Canada’s COVID-19 deaths those over age 80. Getty Images

So the data was there, it was analyzed and the solution seemed clear enough; target the virus aiming for the elderly to defuse its impact, and refuse it the opportunity for wholesale wreckage. The funding aiming to erect a scaffolding of defense earmarked for that specific purpose, the personnel alerted and diverted to ensure that the defence was well directed and maintained to fulfill its purpose. The intention publicly stated but never carried through to fruition.

Instead the focus swivelled to society at large, mandating a general lockdown to protect the greater aggregate of the population, those at least risk for harm among the population. And the aged and the infirm were left to chance. And as it happened chance failed to favour their continued longevity. Such are the best-laid plans of mice and men, when the authors of those plans lack the conviction of their intentions and their attention wanders off target...

The result was encapsulated in the Canadian Military report on their findings in a select few long-term care homes in Ontario and Quebec as compelling evidence of a failed initiative. Outlining the case for blaming an uncaring industry whose primary interest is financial gain and whose investment in the well-being of those in their care, an afterthought. After all, of the 6,700 coronavirus deaths in Canada, 8o percent occurred in those inadequately staffed, untrained personnel LTCs.

Health Canada reports that over 6,700 Canadians died in LTC facilities -- the vast preponderance of all deaths in the country due to COVID; 97 percent of the deaths were to those over the age of 60, with 75 percent over the age of 80. By May, 3,652 elderly Canadians died in those facilities. The country was locked down to protect the entire public; those living outside such facilities, deemed to be at low risk, but encouraged to self-isolate, where the elderly were unable to, crowded into those LTCs.

The targeted risk-management so eloquently and warmly promised by Justin Trudeau simply failed to get off the ground. The casualties of that ill-timed 'forgetfulness' were the grandmothers and grandfathers of those who took shelter at home, wore face masks on rare ventures outside and obligingly heeded government orders. The LTC facilities, on the other hand, were left to attempt on their own, to make improvised changes in a desperate move to protect the vulnerable.

"Despite a well-known, evidence-based demographic surge of seniors unable to care for themselves -- and massive waiting lists to enter long-term care, we spent the last decade mired in a program to rebuild or renovate homes that simply don't work", according to the Ontario Long Term Care Association in its pre-pandemic 2018 budget submission, warning that its employees were at a "tipping point", with overwork, yet over-scrutinized by the media and government.

"Problems hiring and retaining staff across the province has resulted in a system that is under siege", they went on. Was anyone listening? The focus on hospitals and their capacity to care for an unstoppable surge of COVID patients in serious condition simply failed to materialize, leaving an extraordinarily rare situation of empty ICU beds.  

Outside Toronto's Eatonville Care Centre, a body wrapped in a white sheet is rolled out on a stretcher, pushed by a woman dressed head to toe in protective gear. (Chris Mulligan/CBC)

 

COVID Deaths : Correcting The Numbers

"[Right now Canadians only know about those people who have died from the novel coronavirus after being diagnosed with it]. But there may be people in the community -- in fact there likely are -- who are not being captured by this process."
"One of the cleanest ways of accounting for those 'missed' deaths is to compare the number of deaths now to the same time period in previous years." 
"We can get a sense as to how wrong or how right our existing models were -- and maybe improve them down the road."
Professor Raywat Deonandan, epidemiologist specializing in global health, University of Ottawa

"We have observed anecdotally people presenting late in the course of their cardiovascular illness."
"So instead of calling 911 after 20 or 30 minutes of pain, they're waiting a longer period of time."
"People can get the attention they need."
Dr.Rob Beanlands, head, division of cardiology, University of Ottawa Heart Institute

Healthcare workers do testing at a drive-thru COVID-19 assessment centre at Etobicoke General Hospital in Toronto on April 21, 2020. Because of massive data gaps, the coronavirus death toll likely is being underestimated.

There is a formal, declared death rate of COVID-19 in Canada collectively, and the provinces also deliver regular updates on deaths due to the novel coronavirus. But these numbers register those deaths where the presence of COVID has been diagnosed. There are many suspected instances of death where no diagnosis has taken place, where people have died at home or in hospital or in care homes and though COVID might have been involved in their deaths, without a test and diagnosis, the cause can be attributed to conditions outside of COVID.

Now Statistics Canada, the federal numbers-gathering agency, is preparing to identify the "extra" deaths taking place in Canada, over and above what is considered a normal rate, based on previous months and years on average. The agency has plans for the release of an analysis on "excess deaths", considered a measure of the number of deaths occurring beyond expectations in the country, aside from the numbers COVID-19 is seen to be directly responsible for.

Examining the total number of deaths from any cause and comparing that with historical averages, according to epidemiologists, can offer a more reliably complete idea of the impact of the pandemic, given that it can include people who have died from COVID-19, despite not having been diagnosed, or people who died while awaiting (postponed) surgery. Plans are for Statistics Canada to compare death rates in the first three months of 2020 with the rates in the first three months of the previous year.

The goal is to publish more timely information on deaths, working alongside provincial and territorial vital statistics offices. News of the planned data release has been welcomed by Canadian epidemiologists, as a means by which a deeper understanding of COVID-19's human toll can be achieved. Official figures released by authorities has the number of lives the disease has claimed as 4,567 throughout Canada. Epidemiologist David Fisman of University of Toronto views excess-death data as critical. "This is the ultimate metric of the impact of COVID-19, and whether we make it better with these very costly measures we've taken."

People who have died from what has been attributed to flu or stroke, but could be seen to be linked to COVID-19, and not ending up in the total count of COVID deaths reveals a real shortcoming in the system of data-gathering. As well, information on excess deaths is critical as well in assessing accuracy of pandemic models. A number of questions could be answered with an analysis of excess deaths in Canada:

• Are a significant number of undiagnosed people dying at home from COVID related issues?
• What is the effect of drop in the number of people seeking emergency help at hospitals?
• Has there been a rise in the mortality rate for other diseases?
• Has there been an increase in suicide rates?

In the city of Ottawa 13 percent more obituaries were published in April than in March (863 and 761 respectively). Montreal, hard-hit by COVID, saw a 45 percent increase in obituaries between March (606) and April (876), while also seeing a 38 percent jump on obituaries in April in comparison with 2019. Dr.Beanlands, head of University of Ottawa Heart Institute, notes emergency room visits have decreased by up to 50 percent during the pandemic, and people arriving at the hospital with major heart attacks decreased as well by up to 30 percent.

What is obvious is that people have been deterred from seeking timely medical attention. The concern at the heart institute is that people fear arriving at the hospital because of the fear of the perceived presence of COVID. Anyone with severe symptoms, Dr.Beanlands stressed, should call 911, and those concerned by their symptoms should contact their family doctor or specialist, many of whom offer virtual visits, while the heart institute itself has taken significant measures to protect against COVID-19.

In contrast to Canada's approach up to now, Europe published weekly mortality statistics, provided by 24 countries, analyzed by a network of epidemiologists, the network estimating that the pandemic has caused 149,447 excess deaths. In the United States, similar data is published by the Centers for Disease Control and Prevention. The death count surged to six times the normal number in New York City, according to an analysis undertaken by the New York Times.

Interestingly enough, and as has been seen in India with a dramatically plummeting traffic accident death rate, the lockdown has seen fewer traffic fatalities, since the bulk of the population is heeding the stricture to remain at home, and this trend should also be taken into account through analysis of excess-death numbers during the pandemic.

Royal Papworth Hospital in Cambridge, Britain

Neil Hall/Getty Images

"Definitely, if we are just counting COVID-confirmed deaths, we are underestimating the true death toll of COVID on Canadian society."
"There are a lot of things to take into consideration. That being said, it sounds like a lot of European countries and the U.S. have been able to produce this sort of data and publish it on a weekly, if not monthly, basis. Hopefully, COVID-19 will allow us to expedite the process here."
"On the end of the person filling out the paperwork, that usually has to be done in a prompt time. Depending on the province, it’s usually within 48 hours, or quicker if possible."
"Right now, the medical system is very focused on treating acute COVID. Sometimes if things are considered non-urgent, tests are being delayed , procedures and surgeries."
"What will the consequences be? It’s hard to know, but timely data about deaths will help doctors understand, and react."
"We may see an increase in breast cancer, colon cancer or cervical cancer."
"Having that all-cause mortality data would be important. So we see that maybe the number of strokes or heart attacks has significantly increased, so maybe it’s time for more public messaging to tell people: these are the signs and symptoms of a stroke or heart attack; do not ignore it, go to the hospital."
Dr.Jennifer Kwan, Burlington, Ontario