COVID-19, Nursing Homes, and Public Philosophy

At the beginning of April, I wrote an essay (here) for BIOPOLITICAL PHILOSOPHY about COVID -19, nursing homes, and vulnerability, in which I argued that the escalating number of deaths in nursing homes was a consequence of the nature of the institutions themselves rather than due to some inherent vulnerability, that is, some property or characteristic such as age or an “underlying condition,” that the residents of these institutions embody or possess. The essay, which offered details about some of the appalling conditions within the institutions, has been read or listened to thousands of times during the past 24 days, setting off a chain of events that has increasingly exposed these conditions of the institutions. The day after the essay was posted and linked from Daily Nous, André Picard, an ethicist who contributes to Canada’s The Globe and Mail, wrote an article about COVID-19 and nursing homes for that national newspaper. And the rest is history.

Yesterday, both the Prime Minister of Canada and the Premier of Ontario finally admitted on national television that “the system of long-term care is broken.” Unfortunately, no one in the mainstream news media has explicitly acknowledged the role that my essay at BIOPOLITICAL PHILOSOPHY has played in pushing the consciousness of Canada’s elected officials and major news outlets to this point nor has any philosophy department or organization offered me (say) employment or some other opportunity because of the social and political significance of the essay. Despite the circumstances and events that have shaped this unprecedented pandemic, the philosophical community remains, even now, primarily concerned with the situations and perspectives of people who are nondisabled, young, and otherwise socially privileged.

More than six years after my father died in a Chartwell-owned nursing home due to institutional negligence, however, I am proud about both the role that the essay has played in the potential transformation of policy and practice for the lives of seniors and disabled people in Canada and the subversive public philosophy that BIOPOLITICAL PHILOSOPHY produces more generally, serving marginalized constituencies within philosophy, academia, and beyond.

In this post, I want to offer details about what that led me to post the essay on April 1 and how it precipitated a national discussion about the ways in which seniors and disabled people are removed from Canadian society, that is, a national discussion about how the apparatuses of ageism and ableism, in concert with the apparatuses of racism, classism, and sexism, condition Canadian society, a discussion that is ultimately about neoliberalism and the eugenics of normalization that facilitates it. By offering these details, I aim to indicate gaps that remain in the expanding discussion.

Throughout March, I watched the events that unfolded at Lynn Valley nursing home in North Vancouver, the mounting number of deaths occurring in nursing homes in British Columbia, and the daily news briefings with Dr. Bonnie Henry, Provincial Health Officer for B.C. At the end of March, Rosemary Barton, Chief Political Correspondent for the Canadian Broadcasting Corporation (CBC), conducted an interview with the attending physician at Pinecrest Nursing Home in Bobcaygeon, the site of the first major outbreak of COVID-19 in a nursing home in Ontario. At the time that Barton conducted the interview, a dozen residents of the home had died of COVID-19. As I write this post, the death toll at Pinecrest stands at 28 residents and 32 people overall, including the spouse of one resident.

The interview was not one of Barton’s better moments. She seemed to know little about nursing homes and how they operate, repeatedly telling the doctor that he was a “hero,” even as he reluctantly indicated to her that the facility and its residents did not comprise his primary practice; that he was a general medical practitioner, not a geriatric specialist; that he did not live in the town of Bobcaygeon; and that he conducted his consultations about residents—including residents who had tested positive for COVID-19—remotely rather than caring for them in person, face-to-face. By the end of the interview, the doctor appeared noticeably uncomfortable. Although Barton seemed to assume that the doctor was upset about the growing number of deaths in the institutions, I got the distinct impression that the doctor was increasingly embarrassed as he relayed this information to Barton, perhaps recognizing, with regret, his complicity in the perpetuation of a gruesome state of affairs.

At the end of the interview, I went to Barton’s Twitter account, frustrated that she had not conducted the interview diligently, urging her to be more critical about what was taking place in these institutions. Ultimately, I felt compelled to write an essay about the situation in nursing homes that the COVID-19 pandemic has almost predictably thrown into relief, an essay that would combine my background in Foucault’s insights about medical knowledge/power, neoliberalism, racism against the abnormal, and institutions; my feminist analyses of oppression, capitalism, and exploitation; and my personal experiences and observations about nursing homes that these philosophical views have conditioned. After I posted the essay to BIOPOLITICAL PHILOSOPHY, I circulated it on social media, tagging Barton, Ian Hanomansing, and Adrienne Arsenault, all of whom are leading news broadcasters at the CBC.

Thus far during this pandemic, mainstream news reportage of the situation in nursing homes in Canada has been restrained and uneven, much of it has seemed uninformed, with too much reliance on “experts” who seem to have little first-hand knowledge of these institutions, yet are called upon for their views about how nursing homes have managed the pandemic, including an infectious disease specialist who works in a large urban research hospital and a geriatric physician who practices in another large urban research hospital. In addition, the CBC has televised the daily press conferences of Canada’s Prime Minster Justin Trudeau, provincial Premiers, and other Canadian politicians and health officers, recycling their rather hollow messages about the deaths in nursing homes and other “long-term care” institutions across Canada. During these press briefings, in fact, Trudeau and some of the Premiers have repeatedly displayed their own lack of familiarity with the terrible living arrangements of thousands of seniors and disabled people in their own jurisdictions, as well as steadily revealed their negligent past disregard for these constituencies. Both yesterday and today, for example, Stephen McNeil, the Premier of Nova Scotia, claimed that nursing homes are real “homes” in which people reside and actually feel “at home” rather than institutions where people merely exist. In almost all cases, nothing could be farther from the truth.

Consider the signifier long-term care facility, the term that popular news outlets and politicians have adopted in the discourse that surrounds these institutions and the pandemic. Long-term care facility is a euphemism for nursing homes, a euphemism that is mobilized for a number of reasons, including these: the term is alleged to be less paternalistic; the term is claimed to de-medicalize the experience of the institution for its residents; and the term is taken to suggest that the institution is less a relic of the past than the barbaric nursing homes of days gone by, providing comfort and security for one’s later years. Nevertheless, long-term care facilities, like psychiatric hospitals, prisons, and juvenile detention centers, operate according to a totalizing and individualizing logic, constituting a homogeneous population in order to make it governable, structuring their days with bed and bath routines, limited food choices, and other regulatory measures. Indeed, the euphemism of long-term care, regardless of the ostensibly well-intended motivations of its initiators, plays a fundamentally performative role in the obfuscation of the actual nature and operations of these institutions.

Little “care” takes place in these institutions, in part because (as is now widely known) they are both understaffed and underfunded. So far, the emphasis of the current discourse about nursing homes in Canada and COVID-19 has been placed on the working conditions of personal support workers (PSWs), and understandably so. Before the pandemic, PSWs,  most of whom are women of colour and newcomers to Canada, were, in many nursing homes, responsible for more than a dozen residents each: toileting, bathing, dressing, feeding, and assisting them in and out of bed, as needed.

Because the workload of PSWs can be overwhelming, family members of residents must participate, often making the difference between whether or not a resident eats a full meal; gets their teeth brushed or not; is washed or not; has their briefs changed frequently; and has the opportunity to engage in conversation on a given day. Although the mainstream media (and politicians) repeatedly emphasizes the active involvement of family members in the daily lives of nursing homes residents, such involvement is not universal. Some residents have no visits from family members or friends. These residents may spend their days alone, in front of televisions in their rooms, or parked in their wheelchairs at the nursing station nearest their respective rooms; may not get adequately fed; may not get washed properly; may not get dressed in clean clothes; and so on. When lockdowns are instituted, the lives of residents are entirely in the hands of the administrators and staff of the institution.

Although the mainstream popular press in Canada, as well as Trudeau and other politicians have concentrated on problems that surround the lack of PSWs in nursing homes, the problems with staffing of these institutions that neoliberal austerity and its bottom line require extends to the working conditions and expertise of nurses and doctors too. Indeed, in most of these institutions, registered nurses (RNs) and registered practical nurses (RPNs) are in short supply. Although the Ontario, B.C., and Quebec provincial governments have now mandated that PSWs cannot, at least for the time being, move between institutions but rather must work at only one nursing home, some RNs and RPNs continue to move between these institutions.

In the Chartwell-owned nursing home in which my father was placed, one RN or RPN was responsible for about 20 residents, which meant that, during a shift, the given nurse had time only to prepare medication, distribute it, do charting, prepare and apply dressings, do charting, communicate with the PSWs and in-house doctor, and do more charting. When a regular floor nurse was absent, for whatever reason, usually she was replaced by a “temp,” that is, a nurse who works for an outside commercial health-care agency and thus travels between institutions, filling in where absences must be covered. Although agency RNs and RPNs are fully qualified, they are generally not familiar with the specific needs of particular residents nor are they necessarily specialists in geriatric nursing. On many occasions, I was required to explain the very distinct protocol of one of my father’s medications to temp nurses assigned to his “neighbourhood” of the nursing home. Under the current measures that the Ontario Ford government introduced to address the dire situation in Ontario nursing homes, the institutions remain permitted to utilize agency-employed temp nurses, increasing the risk of transmission during this pandemic.

And doctors? They too are in short supply at nursing homes, as my remarks about the in-house doctor at Pinecrest Nursing Home indicate. When my father became a resident of a Chartwell home, he and my mother were required to sign documents which stipulated that the institution’s in-house doctor would take over the responsibility for my father’s medical care that had previously been the responsibility of my father’s family physician. Generally, these in-house doctors, who may work at more than one nursing home, visit a given nursing home only sporadically and can be reached only through nursing home staff.

Why do families place their senior members and elders in these institutions? In some cases, senior members of a family are regarded as inconvenient and time-consuming, a burden. In many cases, spouses and other family members of a nursing home resident believe that nursing homes are the only viable option available to them: government-operated home care in Canada is at present grossly inadequate, difficult to access, and unreliable; private home care is not affordable and can be unstable; nursing homes are falsely promoted as safe(r) and interactive environments; waiting lists for nursing-home occupancy are long and vacancies offered must be secured within a small window of time, usually a few days, making the process coercive and punitive; and critical information and analyses about how these institutions actually function and why have not been produced and circulated widely.

Like prisons, psychiatric hospitals, and other carceral institutions, nursing homes serve a fundamentally constitutive role in the neoliberal expansion of the apparatuses of ageism, ableism, racism, sexism, and classism; that is, nursing homes, rather than merely an effect of these apparatuses, are mechanisms of their governmentality. Trudeau, Ford, and various other Canadian officials have pledged to “rehaul” the long-term care system in Canada. Until and unless Canadians and Canadian government officials acknowledge the power relations that condition these institutions, however, any attempt to ameliorate the system will likely reincarnate its egregious and violent character in other guises. Indeed, we mustn’t rebuild the system of long-term care institutions but instead must render it obsolete.

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