Whither An Old Problem: Sweden, New York, and Problems with Elderly Care

Signs at the Sahlgrenska hospital emergency reception requiring virus patients to stay outside and call for help. Taken during Corona outbreak 2020. Photo by BIL via Wikimedia Commons

All the way back in April, Mike Siegel took to Ordinary Times to write about the issues that came with touting the “Swedish Model” that seemed to be far lighter on quarantines/shut downs than other European countries.

The post was written a week ago and was proclaiming Sweden’s approach a success. Since then, everything in the post has fallen apart.

The post touted Sweden’s COVID death rate of 40 per million as less than a typical flu season. It has now soared to, as of this writing, 90 per million, blasting past numerous countries, including the United States.
The post touted that Sweden had only 401 deaths to Switzerland’s 715. Since then, Sweden had soared to 899 deaths while Switzerland has slowed down slightly to 1106. Moreover, the number of new infections in Switzerland is falling while the number of deaths has plateaued. Sweden’s numbers appear to be rising.

The contrast to Norway, which is Sweden’s neighbor and has about half its population, could not be more stark. Norway adopted one of the most aggressive approached to COVID. But they have only 128 deaths so far, less than a third of Sweden’s death-per-million rate. Their rate of new infection is falling and their rate of new deaths is either flat or falling.

Finally, it’s not clear that Sweden is avoiding an economic crash. As of March 31, they had lost half a million jobs, which would scale up to 15 million in a country like the US. Their optimistic projection is for a 9% unemployment rate at the end of the year, which is similar to projections for the US if COVID fades.

In short, everything we are being told by the “BUT SWEDEN” crowd is already outdated and being proven wrong. They are not containing the virus. They are not protecting their economy. And they are rapidly rethinking their approach.

Fast forward a month, and there is more data from Sweden, but this time it isn’t guesses and projections.

The BBC:

Most of the 3,698 people who have died from coronavirus in Sweden so far were over 70, despite the fact that the country said shielding risk groups was its top priority.

Sweden, with 10m inhabitants, has kept more of society open than is the case in most of Europe.

“We did not manage to protect the most vulnerable people, the most elderly, despite our best intentions,” Prime Minister Stefan Löfven admitted last week.

Sweden did ban visits to care homes on 31 March. But as in many European countries, relatives, staff and union officials have shared concerns that protective clothing arrived too late, and that some staff may have gone to work at the start of the crisis despite showing symptoms of Covid-19.

Now, increasing numbers of workers are also coming forward to criticise regional healthcare authorities for protocols which they say discourage care home workers from sending residents into hospital, and prevent care home and nursing staff from administering oxygen without a doctor’s approval, either as part of acute or palliative (end-of-life) services.

‘We were told not to send them in’

“They told us that we shouldn’t send anyone to the hospital, even if they may be 65 and have many years to live. We were told not to send them in,” says Latifa Löfvenberg, a nurse who worked in several care homes around Gävle, north of Stockholm, at the beginning of the pandemic.

“Some can have a lot of years left to live with loved ones, but they don’t have the chance…because they never make it to the hospital,” she says. “They suffocate to death. And it’s a lot of panic and it’s very hard to just stand by and watch.”

Much of the coronavirus debate over the elderly, and those of the elderly who are in care facilities in particular, is an extension of the ongoing debate on end of life and palliative care that we have been having for decades. With coronavirus hitting the elderly particularly hard, topics like how much care and resources to give the elderly are raging again with even more potency. Folks who are big on talking points and light on humanity are quick to conclude that preventing coronavirus deaths is not worth the economic impact. The other extreme, that even one death is too many, is just as loud and insistent.

There is no perfect answer. There may not even be a good one. There was no one-size-fits-all answer about the care of elderly patients before the pandemic; there’s not one now. I’m reminded of my own grandfather, who received a cancer diagnosis at an advanced age. When the doctor went into his spiel about “with men your age we usually don’t worry about it”, he interrupted with “exactly how long did you plan on letting me live, doctor?” His provider relented, they pursued a more aggressive treatment, and he lived another 15 years before dying just short of 90 and not of cancer.

But for every one of those types of stories, of course, there are many others where the limits of medicine have been reached and some brutally hard decisions have to be made. Then there are the truly awful and tragic stories of folks who don’t even get the chance to make the decisions at all, either from a system that let them fall through the cracks, through medical incompetence, or through their own decision making and planning.

Of course, some parts of America are not doing any better with elderly in care facilities than our Swedish friends:

Gov. Andrew Cuomo today continued to push back on criticism about the state’s number of coronavirus deaths in nursing homes, one week after the state began requiring more testing and ensuring that fewer positive cases entered the facilities.
A quarter of the more than 22,000 people who’ve died of the coronavirus in New York state have died in a nursing home, according to state data. As of Saturday, 62 have died in nursing homes in Onondaga and Oneida counties.

“Older people, vulnerable people, are going to die from this virus,” the governor said today when asked about whether more should have been done to protect nursing homes residents. “That is going to happen. Despite whatever you do.”

Yet for many weeks, New York policy allowed nursing homes to accept positive Covid-19 patients back into nursing homes, some of which were not routinely testing staff and residents.

State officials said they couldn’t discriminate against those who’d tested positive. Cuomo also said last week that, at the time, there was also fear that hospitals would run out of beds for new, incoming patients. In mid-April, more than 18,000 people were hospitalized across the state with Covid-19.

“I said from Day One, the fear is we overwhelm the hospital system,” Cuomo said, today invoking images of people dying in the hallways of Italian hospitals before they could get care.

At the same time, the state required nursing homes that could not adequately care for coronavirus residents — including quarantining them — to seek help from the Department of Health so that those people could be cared for elsewhere. That remains the case, the governor has said repeatedly.

Finally, a week ago, Cuomo signed an executive order barring hospitals from sending infected patients back to nursing homes. That same order now requires all nursing home staff be tested for the virus twice a week.

Aside from government decision making, there are two immutable facts about the coronavirus that were apparent from the start and are still true today: people are going to die, and there is going to be economic pain from the reactions of the living. The final numbers of both has been, and still is being, negotiated. Like all negotiations, the newness of the present crisis is filtered through our priors, from the average citizen to the government officials making the calls. It’s all guesswork, from educated projections to the stubborn refusals based on political leanings, as Mike concluded his original piece last month:

In the end, it bears repeating: our COVID strategy is a guess based on prior epidemics and our limited knowledge of this virus. The results in South Korea and Taiwan and the flattening of the curve in many other countries indicates that this approach is working, at least for the moment (knock on wood). But it is still a guess, one we should question and one that will improve as we get more data.

The alternative to what we are doing now is also a guess. However, it is a guess based not on scientific data but on validating the priors of the proponents: that these eggheads are wrong and we just need to tough it out as 1/5 of our citizens get desperately ill and 1-5% of them die.

We won’t know for a while how much “flattening of the curve” there was, and we may never know how many illnesses and deaths were prevented by these actions in comparison to total inaction. We also don’t really know how much economic impact there will be over the coming months as folks find out what businesses will, and won’t, survive shut downs, quarantines, and stay-at-home orders.

But regardless of what decisions we make, the elderly across the world will continue to be the demographic most affected by illness. The ever-climbing numbers of dead do not really care about the debates of the living. Perhaps we should consider that when all of us get our own turn on the far side of mortality, some things that seem really important right now won’t matter then. When facing these hard questions with no good answers about life, and when the latter overtakes the former, folks don’t really focus much on “God, I wish I’d spent a few more hours in the office on that Excel sheet.” But they do worry that their loved ones are cared for with the financial resources such work could provide. They very well might think about their favorite restaurant, or travel destination, or time spent with family. The elderly that are in care homes, or cared at home by their families, have plenty of such thoughts and feelings. Sadly, the debates around coronavirus seems to have made most even more callous to our elders than in the before times. Once again, folks who have life and meaning left in them are distilled down to a demographic and covered based on their usefulness to whatever narrative is being wielded at the moment.

We should never let death strip us of our humanity. Not in how we face a crisis, not in how we care for the elderly, not in how we live our lives in challenging economic times. If we let our compassion fall by the wayside, there isn’t much point to life anyway, existence being just one long chase scene from a movie where death stalks us till the inevitable conclusion.

Our care for the elderly was poor before the crisis. If we let our humanity slip even further, then the pandemics of the world really will win a victory over the living. God forbid.