No One Should Be Surprised That America Abandoned the Elderly to Die

The elderly pay a high price for America’s neglect. Photo: Erin Clark/The Boston Globe via Getty Images

Trump is trying to move on. So are state governments. But the novel coronavirus isn’t finished with us yet. In Florida and Texas, hospitals are nearing capacity; to the west, Arizona sets case records. Behind the case counts and hospitalizations, deaths follow, and once again the toll will fall heaviest on the elderly. The virus is lethal for senior adults, but not only because the immune system weakens with age. Though most seniors live at home, adults older than 65 make up just over 83 percent of all nursing-home residents, and 93.4 percent of residents in assisted-living facilities. In these so-called congregate settings, COVID-19 spreads like quicksilver, and can claim dozens in weeks.

By mid-May, around 5,000 nursing-home residents in the State of New York had died from COVID-19. Elsewhere, matters were equally grim. By mid-June, ProPublica recently reported, the virus had claimed 5 percent of all nursing-home residents in Michigan. The total was even higher in New Jersey, where the virus killed 12 percent of the state’s nursing-home residents in the same time frame. Rising case totals in Arizona and Florida promise future suffering for the elderly. Both states are home to rapidly graying populations. Whether they live at home on their own, or in care with other people, for the elderly the next few weeks may be among the most critical of their lives.

“The situation is really dire in our nation’s nursing homes and other long-term care facilities right now,” Rhonda Richards of the AARP confirmed to Intelligencer by phone. The Kaiser Family Foundation, she added, has reported “over 253,000 COVID cases and over 52,000 deaths in these facilities. And these are really horrific totals.” In June, the New York Times reported that 42 percent of all deaths from COVID-19 could be traced to a long-term care facility, a figure that includes residents and workers alike.

These horrific totals were not inevitable. The virus is an efficient killer, but it has accomplices. In New York, ProPublica reports, Governor Andrew Cuomo may have placed nursing-home residents in unnecessary danger. By requiring facilities to accept all medically stable patients, even if they were COVID-positive, and prohibiting them from testing would-be residents for the virus, Cuomo opened their doors to infection. New Jersey enforced a similar policy, with similarly deadly results. Governors calculated the risks in front of them and, as hospital beds ran low, shifted the burden to those least able to shoulder it. Forcing the sick into nursing homes may have relieved local hospitals, at least for a while. It also sacrificed the elderly and the disabled to disease – though that’s a conclusion the state of New York itself disputes.

In an email to Intelligencer, a spokesperson for Cuomo insisted that New York “has taken aggressive action to protect nursing home residents from COVID,” including the provision of “14 million pieces of PPE, establishing a staffing portal that was used by 400 of 600 facilities in the state, requiring health screenings and testing of staff, and banning nonmedical visits.”

“The Department of Health’s advisory memo - based on guidance from the federal CDC and CMS - said facilities can’t discriminate against residents based solely on COVID, and underpinning that memo is S10 N.Y.C.R.R. Section 415.26 which says a nursing home shall accept and retain only those residents for whom it can provide adequate care - that means cohorting sick residents and other infection control measures,” the spokesperson, Peter Ajemian, added. “If the facility couldn’t ensure proper levels of care, they had no business taking the patient. Ultimately, DOH’s peer-reviewed report found that asymptomatic staff – not admissions from hospitals – were the driver of nursing home infections or fatalities.”

In the U.S., seniors are often an afterthought. Though elderly Americans receive Social Security and Medicare benefits that lift millions above the federal poverty line, other, more precise measures of economic hardship suggest that senior insecurity is higher in the U.S. than in many other wealthy countries. Research informed by the Elder Index, which was developed by the University of Massachusetts Boston to track senior poverty, found that half of all seniors who live alone lacked the means to cover basic expenses; among two-senior households, nearly a quarter reported the same. Many of those low-income seniors continue to work, or enter poorly regulated care facilities that can pose unique dangers to their health.

“This is a group who is already living on the edge,” explained Kevin Prindiville, the executive director of Justice in Aging. “Because they have low incomes. They have limited work opportunities. They have limited social support in their community. And then you add to that this virus, which is particularly dangerous for them. It just exacerbates all the challenges that they were living with before.”

As coronavirus carves through the elderly, it tells us something ugly about the high price of the American project. The prosperity it engenders is real but limited; it is exclusionary by design. Wealth flows upward, where it stays, and creates an inverted pyramid that bloats at the top then vanishes to a fine point at the bottom. Proper care for the elderly and for people with disabilities requires what some corporate executives might call a restructuring — an unpalatable task for those already at the top. Coronavirus lays the consequences bare. In the U.S. the elderly and the disabled aren’t quite unworthy of life, fit only for extermination. But they exist somewhere in the same hostile neighborhood. Life is expensive, which makes it a luxury. Whatever care we extend to the aged we consider a gift, or an act of charity, and not something we owe them because they exist.

The culling of the old appears often in speculative fiction, where it reliably signals a society that is sick, evil, or deeply dysfunctional. Logan’s Run is undeniably goofy, but the film’s sacrificial 30-year-olds exaggerate real ideas. If prosperity is fragile, it must be rationed; at some point we all become dead weight. When the absence of children unbalances the world in The Children of Men, the elderly drown in groups. It is a ritual of state, this act of departure. The elders wear white and carry flowers, “like a bevy of dishevelled bridesmaids.” If they hesitate, the police push them back into the sea to die. Margaret Atwood, in her 2014 short story Torching the Dusties, imagines a similar future. Children are born but inherit an unequal world, the existence of which they blame on the old. Authorities don’t formally sanction the atrocities that follow, but they don’t interfere either. “They say they want us to make room. They want us to move over. Some of the signs say that: Move Over,” one character says to another, who responds, “That means die, I suppose.” It does.

Fiction caricatures tendencies that already exist. In its own way, so has the pandemic. Human beings did not design the coronavirus, or bestow on it the biological qualities that make it so dangerous to the aged; neither did human beings beings deploy the virus to kill the elderly. But decisions made by humans about how to direct their resources in response the to virus can exacerbate the danger or not. And the the priorities they reveal can recall discredited ideas that rank the value of human lives – a kind of eugenics, if unintentional. The politicians responsible for our national triage don’t all share the same motivations: Cuomo and Murphy placed the elderly in life-threatening danger, but it’s possible to read in their efforts a misguided, and subtly biased, attempt to prevent a greater loss of life. Others offer up more cynical rationales, and draft deadlier policies as a result. Cases are rising in Florida, Texas, and Arizona due in part to the decisions of conservative officials, who courted well-known risks in order to reopen their states as quickly as possible.

“No one reached out to me and said, ‘As a senior citizen, are you willing to take a chance on your survival in exchange for keeping the America that all America loves for your children and grandchildren?’ If that is the exchange, I’m all in,’” Dan Patrick, the lieutenant governor of Texas, boasted in March. Patrick’s state has refused for months to enforce strict lockdown measures, ostensibly to save jobs and to preserve the liberties of the unmasked. Now that cases are increasing, Patrick may get the chance to live out his convictions. In the process, he might also take out thousands of other seniors — whether they want to die for the economy or not. By late June, residents in long-term care accounted for roughly 47 percent of all COVID-19 deaths in Patrick’s state.

Meanwhile, seniors like Dan Patrick won’t pay the highest price for the GOP’s economic zealotry. The hammer falls instead on those with the fewest resources. Seniors in poverty or who live with disabilities are the new burnt offerings. There may be no keener example of America’s disposal culture than the situation on tribal reservations. There, the virus exacts a steep toll, and seniors now face cascading dangers. The pandemic is the latest in a centuries-long series of threats; it follows forced relocation, impoverishment, overcriminalization, and broken treaties. Viruses may be an inevitable risk of life on this planet, but policy decisions can mitigate or exacerbate the threat to humans, and to vulnerable humans in particular.

Though the CARES Act included some $8 billion in stimulus funds for tribal governments, the Trump administration delayed payment for months in some cases. Some tribes, including the Navajo Nation, closed their borders to try to slow the spread of disease. They’ve also had to change the way they care for seniors. Larry Curley, the executive director of the National Indian Council on Aging and a member of the Navajo Nation, told Intelligencer that tribes have shut down congregate meals for seniors, choosing instead to deliver meals directly to homes.

“So what has happened as a result is that a lot of the elders are isolated. And most tribal communities are very communal,” Curley added. “They visit one another, they have very deep ties to their families. Now they’re cut off from those social gatherings where they can talk and meet up with their families.”

The psychological damage inflicted by the pandemic is widespread, he said. “Elders are walking encyclopedias and now they’re impacted. Even in my own family,” he continued. “Four of my elders, who are my aunts, all in their 80s, have been impacted. I have a couple of cousins that have passed away from the pandemic. So personally, I have felt it. The traditional ways of burial and grieving, you can’t do that now, and that leaves a hole in a person’s psyche.”

Tribal medical facilities, meanwhile, are underresourced and overworked. The Tuba City Regional Medical Center, which serves a largely Navajo population in northern Arizona, is “beyond capacity,” Curley said. When one of his aunts fell ill, she was flown hundreds of miles away to Scottsdale. It’s too far for Curley’s cousins to travel. “So the family is disrupted,” he explained. Overall, he added, the pandemic “is going to have a major impact. Not only by changing communities, or on health. I think there will be something like PTSD in the elders.” The Navajo Nation has reported 7,914 positive cases of COVID-19, with 378 dead.

“I keep hearing from Indian people who say, we survived the smallpox blankets, we’ll survive this. I love the optimism, but I think one has to be realistic as well. This is going to have a profound effect on Indian country,” he added.

Native seniors face threats specific to their circumstances. But they also aren’t the only ones in trouble. People of color are overall more likely to age into poverty. Abandoned by a patchwork system of eldercare, they were vulnerable long before COVID-19 struck. “Often the lowest-quality nursing homes are the ones that serve the greatest proportion of Black and brown older people,” Prindiville explained. Those facilities, which tend to be loosely regulated and often pay workers poverty wages, have since become viral hot spots. It’s a situation Prindiville believes that facilities could have prevented if they tried. It’s not a problem of financing, he added. “We’ve seen evidence over the last ten years that nursing facilities are highly lucrative, and have become places where there’s actually a lot of private-equity investment as part of broader real-estate investment packages,” he said. The profits just aren’t trickling down. Not to workers, and not to residents either.

For seniors and the people who love them, the pandemic sets up an urgent question. What could a more humane system of eldercare look like? Richards, with the AARP, said there are some immediate remedies that her organization favors. The AARP has lobbied Congress for better protective gear in long-term facilities, in addition to better staffing and improved transparency from facilities themselves. “We think also that the care facilities need to report publicly on a daily basis if there are confirmed COVID cases,” she added. Nursing homes, meanwhile, are fighting transparency as hard as they can; according to the AARP, nearly 20 states have passed laws or issued orders that grant long-term care facilities broad legal immunity for actions undertaken during the pandemic. The AARP opposes those measures.

Prindiville, meanwhile, describes the fight ahead in broader terms. “Too often, once older people have high needs we seek to institutionalize them, to segregate them, to put them somewhere else that is separated from their community,” he said. “And to us, that major system reform that we could be looking at out of this pandemic is to dramatically shift away from that overreliance on institutions, particularly these nursing facilities where they’ve got 150 people living together and they’re all high needs.” To Prindiville, that means creating supports for caregivers and seniors alike so that they’re less isolated, and more integrated into community life. That might look like building facilities into neighborhoods, where the elderly can mix with families and young professionals, or making facilities small, with plenty of light and green space, as Justin Davidson recently explained for Intelligencer.

The long-term solution, in other words, may be to recognize something that should have been obvious a long time ago. The elderly are no more or less human than they were in their 20s. They aren’t a contagion to be sequestered, or a burden to reluctantly tolerate. Whatever system we build from the ruins of the moment, it ought to be as inclusive as the experience of old age itself.

This piece has been updated to include comment from a spokesperson for Governor Andrew Cuomo.

America Is Sacrificing the Elderly to Coronavirus