A Crisis in Care

The coronavirus could not have found a more suitable Petri dish than nursing homes in America.

Residents and workers at those facilities comprise about 40 percent of deaths from COVID-19 in the United States. That should be no surprise, since many nursing homes — around 43 percent, according to a Pro Publica investigation — lacked a legally mandated emergency plan when the pandemic struck. Lax regulation created little impetus to focus on disease prevention, and the chaos was compounded by new guidelines that allowed less training of staff. Some homes failed to inform family members that their parents were ill. Others hid the extent of viral spread.

Despite all this, legal action has been stymied by the exemption of nursing homes in many states from wrongful-death suits. Wrenching images of residents being carted off to the hospital or the morgue cannot convey the systemic nature of this failure. It is nothing less than a culling of the old, and it stems from an indifference to their welfare that belies the pretense of concern. So pervasive — and yet, undetectable — is this dismissive attitude toward the elderly that it rarely seems like a prejudice. The honorific “senior citizen” is deeply ironic, given what has transpired not just in America but all across the Western world.

The problem extends beyond the United States. In some European countries, nursing homes were excluded from planning for the pandemic, and their residents were missing from statistical models that guided the response.

In Belgium, an untold number of those over sixty-five who fell ill from the virus were denied admission to hospitals, though there were enough beds to accommodate them. A New York Times investigation found that this was true even when the sick were likely to benefit from intensive care. Instead, these patients were sent back to their nursing homes, where they were treated with morphine and, as one physician put it, “comforted to death.”

In Sweden, protocols advised the same course of treatment: morphine instead of oxygen. By October, nearly half of Sweden’s coronavirus deaths had occurred in nursing homes. In Spain, more than 4,500 investigations have been opened after the bodies of residents in care homes were found abandoned in their beds.

COVID-19 has exposed the truth about how old people who cannot afford private attendants — that is to say, most old people — are cared for. But they are also placed at risk by government responses that have enabled the virus to spread.

When Sweden decided not to lock down its population, reasoning that the most vulnerable would simply stay home, the death toll was nearly six times higher than in more cautious neighboring states. By some estimates, 90 percent of those fatalities were in people over the age of seventy. When Britain decided to open restaurants and pubs last summer, 88 out of every 100 deaths from COVID-19 were in people older than sixty-five.

In both nations, proud of their public health systems, doctors admit that they sometimes turned nursing-home patients away from the hospital. This is not just poor planning; it is criminal negligence. European Union member nations blurred the line between euthanasia and murder.

In America, death is only part of the suffering inflicted on the elderly during this pandemic. Though recessions generally affect newly hired young workers, in this crisis, older employees have been more vulnerable. Their jobless rate is now the highest it has been since 1948, as strapped companies dismiss senior workers rather than pay higher insurance costs and mandated raises. Age discrimination is illegal, but proving such cases is notoriously difficult. Nor is it easy for unemployed seniors to find jobs. We may soon see millions of people too young to retire and too old to work.

Fatal Neglect

Yet despite a health crisis that offers glaring proof to the contrary, most old people in America don’t think of themselves as victims of a bias. Their ranks span the categories of race and class, and the beneficial effects of Social Security and Medicare strengthen their sense of being valued. The culture colludes in this image of comfort and contentment. Drug ads show the elderly frolicking with puppies and grandchildren. In the sitcom-verse, they are Golden Girls and Sunshine Boys.

There are senior centers in many communities, cosmetic processes for every sag, rounds of applause for nonagenarians who run marathons. Age is no barrier to political success. But the aura of well-being is fragile, dependent largely on wealth and race. When society must choose between reviving the economy and saving lives, the interests of the aged are marginalized. Their need for safety is met with inefficiency or inaction. Disregarding old people is nothing new, but this pandemic is a grim reminder that such obliviousness can be deadly.

The special vulnerability of the old haunts the debate about public policies during the pandemic. Stressing the risk for everyone may be a sound strategy, since it alerts the whole population, but it also diverts attention from the danger that younger people, including those who never develop symptoms, will spread the virus to their elders. The recent spike in cases wasn’t just caused by shoppers without masks and tipplers going bare-faced in bars. The virus was also spread by workers at those businesses, many of whom live in close quarters with multigenerational families.

In Europe, ageism expressed itself in genteel mistreatment; in the United States, it fed a failure to keep the virus at bay in state after Republican-run state. In South Dakota, the governor’s decision to allow massive public events, such as a huge motorcycle rally, produced a surge of cases across the Midwest. In Florida, the governor reopened businesses and beaches before the infection rate was low enough, and he required staff at nursing homes to be tested for the virus only once every two weeks. As a result of these actions, Florida had one of the nation’s highest COVID-19 case rates. A quarter of its residents are elderly, but their safety did not guide the governor’s hand.

In Texas, where there have been more than a million cases, opening businesses prematurely created a special crisis in immigrant communities, where many people work in the service industries. (About 25 percent of restaurant employees in the United States are Latinos.) The state’s lieutenant governor put it bluntly when he told Fox News host Tucker Carlson that “there are more important things than living.” There is an unspoken assumption behind this remark: some people can be sacrificed for the greater good. Among the expendable: the aged.

When elder-care facilities in Florida asked FEMA for desperately needed safety equipment, the agency sent shopping-bag gowns and masks made from recycled underwear, with fragile paper straps. As the caseload reached its apex in New York, the state had to compete with the federal government — as well as other states — for extra ventilators. New York governor Andrew Cuomo railed at the inept response from Washington. “Whose grandmother should I kill?” he fumed at the feds.

But Cuomo’s own insistence that nursing homes accept infected patients leaving the hospital may have spiked the death toll in such facilities. Roughly 6,400 New Yorkers perished there, including many grandparents.

This pandemic has provoked the question afresh of how we as a society value life. Which lives are most valuable? If economic activity is the point, younger patients should matter more, since they are likely to work for many years after they recover. Only 16.4 percent of people over sixty-five are still in the labor force, so the survival of the old is less crucial when it comes to productivity.

Preserving their lives is largely a moral imperative, and when a crisis like this strikes, that obligation becomes more tenuous, because the only payback is that they will remain alive. In a society shaped by profit, the aged seem less useful and therefore more disposable. Many euphemisms hide this uncomfortable fact.

Ageism’s most virulent form emerges in times of distress. It masks itself in reason and denial under the pressure of scarcity. This is why the death toll from COVID-19 should not be regarded as a purely medical phenomenon. It must also be seen as a product of bigotry. It has to be said, clearly and angrily, that when the old die in great numbers because they cannot count on their leaders to protect them, it is a crime. Let us call this fatal neglect what it is: geronticide.

The Coming of Age

The first step toward confronting this injustice is to understand that growing old is not just a biological event. It is also a social process.

There is no schedule for senescence: it occurs differently in each person. The loss of strength and stamina that cannot be fully hidden by fitness or botoxed away — these are signs, but not necessarily evidence of incapacity. Yet, at a certain age, one enters the order of the elderly. As Simone de Beauvoir notes in her magisterial work The Coming of Age, “the aged person comes to feel old by means of others.”

Though race and class make an enormous difference, most old people suffer a decline of income and status when they lose their place in the working world. Over time, internalizing society’s judgment leads many retirees to feel useless and powerless in their bodies and minds. This is not so different from what other oppressed groups experience. Yet there is no woke lexicon for the toll that ageism takes. The same culture that plies the old with products to hide their deterioration also pacifies them. For all that they are encouraged to be youthful, enveloped in a nimbus of bright colors and tinted hair, they must accept their marginalization.

COVID-19 has tightened the boundaries that were already drawn around the old. They have always been expected to occupy separate spaces. So why should we shut the economy to maximize their safety? Let them do what they should do anyway: stay out of sight. This dismissive attitude underlies the rationale for refusing to wear a mask.

Of course, different cultures produce distinct responses to aging. Latino communities in the Southwest are more likely than the Anglo communities around them to emphasize protecting their elders; wearing masks is often associated with caring for one’s grandparents. This ethic of familial solidarity has been cited by Pope Francis, who recently issued a strong protest against discarding the aged like “waste material.”

Though his statement does not mention the pandemic, its timing is significant, as is his critique of societies “planned on efficiency, which consequently ignore the elderly.” Such systems, he says, “are perverse.”

A vast industry is dedicated to housing and assisting seniors in dedicated spaces. The real purpose of these institutions is revealed by the fact that reforming them has no political traction. Segregating old people assures that they will not disrupt the flow of normal activity with discomforting reminders that we are all subject to decay. They will not raise intense feelings of pity and disgust that might sour the shopping experience. Personal violence against them may be scandalous, but the collective dimension of neglecting the old is lost in the space between sentimentality and silence.

A heartwarming segment on the CBS Evening News shows teenagers delivering groceries to the homebound elderly. This is a touching tribute to human kindness, but the problem of sustaining old people who cannot wait in mile-long food lines is too massive to be solved by volunteers. To meet their needs requires an organized public response, and the fact that no such effort is being made shows how dispensable they are. We have no idea how many seniors are suffering from malnourishment because they are afraid to go outside; how many have delayed crucial medical procedures or suffered unbearable symptoms of dementia in isolation. No one reminds us that, when Donald Trump says only 1 percent of COVID-19 cases are serious, he is rendering the old invisible.

I have been called a fascist for reminding people to wear a mask. “I’m old,” I said to one man, by way of explaining my insistence. “So stay home,” he replied.

I took it in stride because in New York City, where I live, irritated candor is a way of life. But I also understand that chronic stress unleashes the resentment beneath gentility.

The inequities of capitalism, intensified by this disease, pit the interests of the young against the survival of the old. With jobs disappearing at a stunning rate, it is hard to sacrifice for the benefit of those who are cushioned by pensions, as I am. No wonder the whispered name for COVID-19 is “the boomer remover.”

“Why is your party more important than my life?” I want to shout when I run into a gaggle of maskless revelers. But I don’t, because this is a social question, and it doesn’t really have a personal answer.

Instead, I try to coax them into raising the swaths of fabric dangling decoratively under their chins. If I am unpersuasive, they peer at their phones blankly. I can’t blame them. When I picture myself at twenty-five, keeping a distance from the promise of intimacy — why would I do that, if I didn’t think contracting the virus would be the end of me? My hormones would impel me to conclude that I am giving up urgent joys just to keep some geezer alive. I regard any young person willing to do that as a hero. But at their age, I was less than that. “Don’t trust anyone over thirty” was my motto in the 1960s. Why should this generation treat me differently?

The answer is leadership. Most of us are an amalgam of moral possibilities, and the behavior we display reflects the values around us. American individualism is often blamed for the mask wars that have engulfed the nation, but that free-bird attitude didn’t prevent us from mobilizing in other times of crisis. The incendiary chaos of today is the product of free-market conservatism. Forty years of dominance by that worldview, even under liberal presidents, have shrunk the sphere of collective action, and when the virus arrived, we were unprepared to deal with it.

Trump exploited this haplessness by conflating it with freedom. He convinced his followers that there was no need for them to worry about a blue-state virus. In this fantasia, the aged are merely collateral damage, but there is nothing incidental about their deaths. Many of these old people are not just casualties of COVID-19. They are also victims of a society with a hierarchical view of whose lives matter.

At the height of the crisis in New York, when the sound of ambulances cut the silence, and a refrigerator truck was parked at the urgent-care clinic up the block, I received a postcard “signed” by the president. “Stay home and away from other people,” it read. That was the extent of his advice to me.

I didn’t need to hear it. I stay home because I never know what I will find in the street. I venture forth now and then in quasi-surgical armor, lurking at the edge of sidewalks, weaving past those too oblivious to keep a distance. I retreat from crowds of people drinking and mingling, like a fretful Puritan fleeing from sin.

Only at home, after vigorous cleansing, do I feel truly safe. As I wring my soapy hands for the time it takes to sing two choruses of “Happy Birthday to You,” I see the querulous man I have become. I fear that he will linger within me even after a vaccine is ready. I will always see the specter of a new virus in an unmasked face.

I try to manage my anxiety with information. I parse Anthony Fauci’s words with Talmudic precision. I have seen the film Contagion three times. I track the progress of the virus map by map, blotches of disease covering the country like a rash. Dealing with terror by devouring data is an attempt to know the unknowable through a surfeit of facts. And reasoning does work in the daylight.

But in the dead of night, images of tubes embedded in every orifice wake me. I gulp a Xanax and glide toward dawn.

Collective Action

Even after the danger ebbs, the reflexes that have set old people apart during this pandemic could become a default position for all sorts of policies. We may be entering an era of age apartheid, in which premodern ideas about what it means to be old are revived. Let them withdraw so the rest of us can thrive. We will treat them if they sicken — up to a point — but we will not sacrifice our economic growth to keep them safe. There are more important things than their lives.

This is a scenario that may never come to pass. But given the threat, the old have no choice but to pursue their interests. They must see through the mirage of respect, since it is killing them. And they must seek allies, because there are many marginalized groups in this pandemic, and many more who care about them.

Health workers could play a central role in advocating for the vulnerable; scientists could devise a humane agenda for survival; young people could demonstrate that there is a different course for their generation than the embrace of selfishness, applying peer pressure to those who act irresponsibly. The Black Lives Matter movement could add health issues to its agenda, since what protects people of color against the virus benefits the old of any race.

By joining with all the groups at risk to demand a fair system of vaccine distribution and medical care, seniors could expand and amplify their influence. They are the largest voting bloc, and skillful organizers could direct that ballot power. A new lobby for the aged, far more militant than the AARP, could emerge from this crisis. In swing states, an alliance of the suffering and their loved ones might very well be decisive. It would be a fitting addition to the fight for social justice.

As for an agenda, first and foremost, it must call the system of biases that has imperiled so many people what Pope Francis did: perverse. It must acknowledge the pain of lost jobs and suspended education while insisting that preserving life is the most important thing. It must demand that the old be front and center in media coverage of the pandemic, not just part of the news mix. It must petition international courts so that the civilized barbarism of states that mistreated the old is punished. And it must be clear that, unless such mistreatment is regarded as a violation of human rights, the young will also be its victims, since old people are what they will eventually become.

Just as my generation came together to oppose an unjust war and struggle for civil rights, now we must unite to preserve our lives. One model for this movement is the activism that arose when AIDS struck. Middle-class gay men who had never been politically aware came to see the links between homophobia and the stigma of drug addiction. Not only did the AIDS movement transform the relationship between patients and researchers; it also demonstrated that people with AIDS were fully human, hastening the advance of addiction services and LGBT rights.

This pandemic resonates with a different set of biases, but the strategy of unity and resistance hasn’t changed. Once again, we must fight for the right to survive.