To the Editor — Throughout the COVID-19 pandemic, many have disregarded worry since the virus “only kills old and disabled people”1. Aside from being inaccurate, this reflects the most disturbing theme across COVID-19: society prioritizing comfort and convenience over the safety of vulnerable groups, apparently deemed disposable. The impact of these positions has been seen in long-term care homes (LTCHs) globally2 and significantly in Canada3, where LTCH residents disproportionately represent 81% of Canadian COVID-19 deaths, more than double the average (38%) of all other Organisation for Economic Cooperation and Development (OECD) countries3. Although Canada reports the worst proportion of COVID-19 deaths linked to LTCHs globally, all nations exhibit a concerning trend for the pandemic’s trajectory where society’s most vulnerable are suffering the consequences of apathy.

Apathetic attitudes towards LTCHs existed long before being exposed by COVID-19 (refs. 4,5). Inadequate LTCH funding from provincial governments and pandemic preparation revealed three existing systemic risk factors for poor outcomes among LTCH residents (Fig. 1)3,6. First, LTCHs are structured so residents share rooms (two to four individuals per room)3, making physical distancing impossible. Second, the employment model used in LTCHs require personal support workers (PSWs) to be responsible for multiple residents, with at least ten and as many as over 40 residents in their care7. Additionally, since PSWs receive low pay and are rarely scheduled on a full-time basis8, they must work in several LTCHs to make a living wage, possibly contributing to the spread of COVID-19 between LTCHs9,10. Third, personal protective equipment (PPE) was in short supply during the pandemic’s first wave10. The Canadian military, deployed to LTCHs in crisis during COVID-19, reported a “culture of fear”11 related to using PPE due to the cost of supplies. The ‘doing more with less’ model also applies to seniors and persons with disabilities receiving PSW services in the community, leaving them vulnerable to an uncontrolled outbreak.

Fig. 1: Systemic risk factors leading to disproportionate COVID-19 cases and mortality among LTCH residents.
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Interaction of systematic risk factors, such as inadequate PPE, the PSW employment model and multiple LTCH residents per room, likely contributes to outbreaks of COVID-19 and disproportionate deaths among LTCH residents.

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LTCHs suspended the right of families and caregivers to visit in an attempt to prevent further exposure to COVID-19. Residents lost access to their loved ones, socialization12 and, most importantly, their personal advocates, by relegating family caregivers to visit through window panes13. Without the watchful eye of family and friends, there have been reports of inadequate end-of-life care for residents dying from COVID-19 and non-COVID-19 causes, with some residents being refused treatment in hospitals14 or the option to leave their LTCH. While restrictions were temporarily lifted over the summer, they have been reimplemented, with visits only being allowed for one ‘essential’ caregiver per resident13.

Despite the clear warning of an impending pandemic and previous knowledge of the risk factors in LTCHs, governments and LTCH administrations did nothing to change care modalities which could have protected this population. By October, when the anticipated second wave of COVID-19 engulfed the country, we had seen outbreaks in 30% of Ontario LTCHs15. Unsurprisingly, preparations fell short in many jurisdictions16, leaving LTCHs understaffed and COVID-19 testing centres overwhelmed. Although the Ontario provincial government committed additional funding17 for LTCHs in December 2020, implementation will take place over four years with little immediate effect while LTCH residents continue to die at appalling rates. We can no longer claim to be ‘shocked’ by these events when the human life belonging to vulnerable groups is so frequently devalued.

To paraphrase a popular adage, we can learn much about a society by how the most vulnerable are treated. The pandemic has made it clear that we must change how the healthcare system provides support to seniors and people with disabilities. Across the world, systemic factors have been revealed, continuing to place the most vulnerable at unacceptable risk. Petitioning governments should not fall just to those directly affected, such as families of LTCH residents. Local officials have a responsibility to proactively improve the situation for those likely to lose the most, responding to the international calls to action from the World Health Organization and the United Nations18. While there is a spark of hope with the prioritization of LTCH residents for vaccine roll-out in Canada19, this is dimmed by the recollection that the same government allowed thousands of vulnerable Canadians to die unnecessarily. Lest we forget our parents and grandparents, and remember that they deserve dignity and protection.