There's no quick post-pandemic fix for Canada's long-term care facilities, say experts
It'll take time, money and a wrecking ball — along with a new public attitude toward aging
This is the third in a series looking at lessons learned from the first months of the COVID-19 pandemic, and at how Canada moves forward.
Dini Cameron has watched Canada's long-term care catastrophe unfold with a mounting sense of dread.
The 84-year-old recently spoke to CBC News from the home in Ashton, Ont. she shares with her 86-year-old husband Doug. He's been in a wheelchair since suffering a stroke but the couple "managed for three months without help and did quite well," she said.
"How we will be in the next few years we don't know," she added. "I'm already afraid. I will look for an [alternative] rather than go to one of those (long-term care homes) for both of us.
"Depending on how far gone I am and if my mind is clear, I think I would prefer euthanasia ..."
Pandemics, like the viruses that drive them, attack weak points. The novel coronavirus exploited a weakness in Canadian society — this country's tendency to warehouse its elderly in poorly supervised long-term care homes.
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The result, say the experts, was completely predictable: as of May 25, long-term care residents made up 81 per cent of all reported COVID-19 deaths in Canada.
"This has been an issue and has caused older adults to die of infections prior to this, and this has just really put it in the limelight," said immunologist Dawn Bowdish, who holds a Canada Research chair on aging at McMaster University. She said the poor infection control at long-term care facilities was well known before the pandemic struck.
"In fact, we know that we've had transfer of influenza — which is the next big infectious disease killer of older adults — between homes because people worked part-time, because they moved from home to home, because we don't have the same infectious disease control that COVID has shown us that we so desperately need."
Long-term care with long-term problems
The SARS outbreak of 2003 led to strong recommendations to improve the management of long-term care facilities, she said — recommendations that faded from view once the crisis passed.
"People cut a corner when you need to cut cost," she said. "It's easy to do because one hopes it never happens. But now we're paying the price for that."
Dr. Sandy Buchman, president of the Canadian Medical Association, said no one should assume that the shockingly high number of deaths in long-term care facilities is due entirely to the age and frailty of the people living there.
"It's an absolute tragedy what happened to elders that lived in Canadian long term care facilities," he said. The CMA has convened an advisory panel of experts to recommend preparations for the next pandemic.
"It's not just about their biological vulnerability ... If you were a senior at home with the same vulnerabilities, you were one hundred times less likely to die than you were if you were in a long-term care institution.
"So it was about the staffing issues. It was about the underfunding. It was about personal support workers having to travel between different long-term care homes. So there are system issues that need to be addressed."
Michael Villeneuve, chief executive officer of the Canadian Nurses Association, will sit on that CMA expert panel. He said the early focus of politicians and policy experts on the pandemic's threat to hospitals — the risk that an overwhelmed hospital system might collapse — led them to focus on that problem at the expense of long-term care.
"We had our eyes over here when there was a really critical problem over there," he said. "And that's got to have a very very close examination before round two comes — if it comes."
No more 'duct tape solutions'
People should start by understanding that the fix for long-term care won't be quick or cheap, said Villeneuve.
"Long-term care needs a long term solution. It's not going to get fixed overnight," he said. "And our concern certainly now at the Canadian Nurses Association is it'll be a sort of duct tape solution — throw a few more staff in and pay them a little bit more and it will be fine. And it won't.
"There are fundamental issues that need to be tackled in long-term care. One is [that] the structure of the physical plant of many of these homes is really old."
Villeneuve said the design of many long-term care facilities helped open the door to COVID-19.
"So you have people in rooms of four or two, or you have a single room with a Jack and Jill bathroom — all kinds of places for disease to move," he said.
"It's hard to imagine but many of those places don't have air conditioning. So one of the things that staff do to make residents more comfortable is they will congregate them in a lounge or in a hallway and put large fans on them to help them cool off. Well, that's a recipe for disaster right there."
Watch: Dini Cameron on why she is worried about moving into long-term care
Demolish and start over
Bowdish argues that, for some older and poorly designed homes, the solution may start with a wrecking ball.
"In Canada, it's really expensive to heat our homes in the winter and it's expensive to cool them in the summer," she said. "So we really love to recycle our air and we know that this virus, because it can live in those itsy-bitsy little two-micron droplets, it can float around in that recycled air for a long time and infect people."
Research shows that SARS-CoV-2, the virus that causes COVID-19, can travel through air ducts and remain suspended in the air for long periods of time. Researchers at the University of Alberta have found that, under certain conditions, airborne droplets carrying the virus can travel tens of metres.
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"Air circulation is going to be increasingly important, and in fact this is one of the reasons we're expecting a second wave" later in the year when the weather changes, Bowdish said.
"Because just like colds and flus, we go inside more, and we breathe more of that recycled air with more of these little droplets with some of the virus in it."
The Ontario Long Term Care Association (OLTCA) has responded to the pandemic and to the dire reports out of some long-term care homes by acknowledging the sector needs help — and by pointing out that it has asked for help before now.
OLTCA CEO Donna Duncan said in a statement to CBC News that "nearly half of the province's" long-term care homes "are older and in need of redevelopment.
"OLTCA has been advocating for a workable program to rebuild older homes for more than ten years."
Trade-offs could hurt home care
British Columbia was able to stave off the disaster that befell Quebec and Ontario long-term care by acting quickly to seal off its homes and banning the practice of staff working in multiple locations.
The lesson seemed clear: pay long-term care workers enough to allow them to live off one salary, and you close off a potential disease vector.
But that risks pitting the long-term care sector's needs against those of the personal care workers who are performing the home visits that allow many elderly Canadians to stay out of long-term care facilities.
Already in Quebec, workers are being lured away from the home care sector by hourly wages of $26 at long-term care homes — about double the rate paid for home visits.
"Pre-COVID, we used to be able to help 12,000 people on the island of Montreal," said Judy Bambach, general manager of the non-profit home care agency Répit-Ressource de l'Est de Montréal. "In COVID, all of us together, I don't even think we're going to reach 750 by the end of this month."
Experts say that if home care falters, more elderly people will end up in long-term care, further burdening the system.
The profit motive
The long-term care sector has many different kinds of players: provincial, private for-profit, not-for-profit and municipal homes all operate together.
Not all for-profit homes in Canada are the same. At one end of the spectrum are modern, comfortable and well-staffed homes that cost over a thousand dollars a week. At the other end are the kind of homes where Canadian soldiers found shocking examples of poor sanitation and neglect.
Bowdish said COVID has revealed a pattern, though.
"We see more deaths in private homes than we do in public homes. And I don't know if we can ever get over the profit motive," she said.
In Ontario, Doug Ford's government moved to take over management of several privately operated homes that were called out in a scathing report by the Canadian military.
"All types of homes have been affected by COVID-19, and each has had a different experience with the disease," said Duncan in her statement to CBC News. She said the OLTCA's "preliminary analysis" indicates that the magnitude of an outbreak at a long-term care facility depends on a range of factors, including its staffing complement, whether it's an older home with multiple beds per room, and whether it received "external support" when it needed it, such as staff and resident testing and personal protective equipment.
'The one good thing'
Bowdish said she hopes this moment might be a catalyst for change.
"Maybe the one good thing that will come out of this whole episode is that we will understand how important it is to have these really basic health care and infectious disease control practices," she said. "And we'll also learn a lot about how to best train the people who work in these homes."
But pandemic measures on their own won't lead to lasting change unless Canadians themselves change the way they think about aging and elder care, she said.
"I think the public has to step up and agree that our elders are important to us," she said. "They're important to our families and our society. They paid their taxes. They worked hard. They deserve the best care in life. And unfortunately that's going to come at a cost."
Dini Cameron isn't holding her breath.
"I don't feel confident at all that the right choices will show up, and that they'll get this under control," she said. "I think those long-term care homes will always look like prisons to me."