COVID 19: The Case for a New Eldercare Model

As we struggle through this pandemic buffeted by the additional tragedy in Nova Scotia, one fact becomes increasingly clear.  As of May 3^rd 2020, 83% of the 37 deaths are seniors living in elder care facilities.  Across Canada almost 80% of the more than 3,600 deaths have been seniors living in elder care facilities, and that percentage is expected to rise.  

As a society we have not cared adequately for our elders.  We have drifted a long way from the idea that you can tell the level of civilization in a society by how we look after our most vulnerable people.  We have forgotten that, as fully functioning human beings, we are both social and individual, and that we are responsible not just for looking after ourselves but each other.  But science, from evolutionary biology to psychology, tells us that we are by nature co-operative and altruistic.  Caring for others is part of our nature.  It has allowed us to just not survive but to thrive.  How did we let our human nature become so warped?  We have become a society where nature and humanity are organized to serve the right of hyper individualized people to accumulate capital. 

This essay looks at the lessons we need to learn from the COVID 19 Pandemic, and then suggests two concrete proposals that will not eliminate risk but will put us in a much better position down the road to provide our elders with significantly improved care and a more resilient healthcare system.  It also is based on the understanding that we cannot understand the serious eldercare inadequacy without understanding the economic and social context that drove the failure.

Lessons

What did this pandemic teach us about our arrangements for elder care?  What problems did it uncover?  In answering these questions it is useful to remember that in our economic system, whenever the return to capital can be increased by reducing how well human needs are met, meeting human needs will suffer.  That includes ensuring the level of taxes on returns to capital are minimized and government revenues and services are reduced to those services designed to protect capital and promote greater returns to capital.  That said the pandemic:

• Showed us how our severe shortage of nursing home beds can hobble our hospitals by having as many as 700 seniors in Nova Scotia waiting in hospital beds for a place in a nursing home.  That meant the ability for hospitals to accommodate COVID 19 sufferers was severely limited.  The COVID crisis was greatly worsened. 
• Taught us that many of our nursing homes have two and three seniors to a room.  People who have lived their adult lives in the privacy of their homes are living their final years with little or no privacy.  They are also far more vulnerable to illnesses that inevitably enter the facilities.  It also reminded us that we made no caring response to the separation of couples who had shared a life time together.
• Uncovered too many facilities that are poorly designed with limited capacity to isolate residents in the event of an outbreak. 
• Brought to light that the front line workers in elder care are, almost without exception, poorly paid.  Many homes deliberately pay as low wages as they can get away with, and in addition hire as many part time workers as possible to both keep pay levels minimum and avoid paying any benefits like sick leave.  This means workers dreaded staying home if sick because they live in or close to poverty.  It also means that many workers worked in more than one care facility to make a bare living.  This means that the virus spread from home to home leading to hundreds more deaths. 
• Showed some homes across the country had so few and over worked staff that there were immobile residents who were almost abandoned in their beds for many hours, and if a few cases apparently for days. 
• Made it clear that low pay was a clear and deep injustice.  Workers who come to work day after day at great risk to themselves and their families clearly know that our economic system sees them as a commodity whose cost can be lowered to increase profit and/or cut government expenditures.  This is true of many essential workers besides direct care workers, including cleaners, janitors and those such as truck drivers who keep eldercare facilities supplied.   
• Produced a reality in which care givers had little or no time to provide information to families, especially after Covid 19 affected staff or residents and urgent workloads escalated.  Many families lost loved ones without any chance to connect with them.  Our elder care demeaned and devalued family bonds.
• Brought to light the inadequate equipment in nursing homes and/or hospitals, and the lack of ready plans to meet the crisis.  The lessons from the SARS epidemic and Ebola were lost in budget restraint.  It also underlined that we were dependent for supplies of equipment from sources that, in a global crisis, were very unreliable.  It became clear that our dependency relationship with the United States is very high risk and even hostile.  We scrambled to develop Canadian sources – will we protect our newly created sources of vital supplies?
• Brought into question the role of private, for profit provision of health care.  Many of our facilities are for profit rather than for care.   There have been far too many instances, even before the crisis, of patients with acute bedsores or being administered levels of medication more consistent with minimizing staff needs than patient wellbeing.
• Taught us once again that government funding for health care is not adequate.  This is an inevitable result of tax cuts to corporations and the wealthy and the unwillingness of governments to deal with tax havens. 
• We learned once again that government regulation of elder care facilities has simply not been adequately carried out, especially for those facilities in which the profit motive competes with care.  ‘Self-regulation’ of these facilities is something they demand, but is granted only at great risk.

Another possible lesson we should examine carefully is the increasing tendency to try and manage government like a business.  Yes, it should be managed efficiently, but increasing the downward pressure on care workers’ incomes is a standard business strategy, but it is unacceptable public policy.  Cutting corners on equipment can increase business profits but is not good public policy.   Cutting budgets for public health and elder care when the proportion of seniors is increasing may allow businesses to be taxed less, but it is appalling public policy.  It is in the national interest to nurture a strong commitment to public service in those who work for the government.  This is not being achieved with a revolving door between government and for profit corporations with business managers and public servants exchanging jobs.   We want efficient and effective government but we cannot afford government that is run like a business.

A Positive Future for Eldercare

There are two significant opportunities that are possible in this time when most people have developed a sense that the old normal is not about to return, and we need to be willing to make major changes to how our society and economy work.  The first opportunity is to ask ourselves what kinds of organizational structures would respond better to meeting human need and enhance our ability to engage people to build a better more caring society.  If we reflect on the lessons above, what type of organization would be most appropriate and likely to perform better?  The for profit business model is simply not appropriate for meeting our need for elder care.  The second opportunity is to ensure the ability of governments to act in the interest of citizens rather than for corporate interests.   

Over a 250 million people around the world work in co-operative businesses.  Their purpose is to meet member and community need.  They produce everything from production machinery, pottery, auto parts, robots and food.  They meet people’s needs for providing financial, marketing, legal, architectural, retail and consulting services.  As well they provide education, rehabilitation and health care.  They are owned by workers, consumers, farmers and small and medium sized businesses.  This is a very flexible business model! 

Are co-operatives perfect?  No, of course not, they are owned by people and perfect people simply do not exist anywhere.  But their purpose is to meet human need rather than returns for investors.  They have an internationally accepted set of values and principles.  They are governed on the basis of one person one vote rather than one dollar one vote.  They have community roots.  The pay gap between the highest paid manager and the lowest paid staff is usually less that 10:1 rather than 300 or 400:1, often found in capital based business.  Their record on environmental issues is not perfect but is better than capital based business.  They are also better at social responsibility.  They have to be financially healthy but they are committed to meeting need rather than maximizing returns to already rich investors.

Adopting a co-operative organizational structure brings with it acceptance of a shared purpose, meeting member and community need, and a set of values and principles shaped by more than 150 years of experience of people working together.  Those values, honesty, openness, social responsibility, caring for others, equality, equity, mutual self-help, self-responsibility, solidarity and democracy.  These are the kinds of values that the victims of this tragedy lacked. 

The co-operative principles include open membership, democratic member control, member economic participation, autonomy and independence, education and training, co-operation among co-operatives and concern for community.  These value and principles, once adopted, become the signposts of accountability for the organization.  Members, governments and the community can look to them as the basis of standards of accountability

So what co-operative structure might make a strong contribution to much better elder care?  In Quebec, and much more so in Northern Italy and the Basque Country of Spain, there are solidarity co-operatives.  They have different classes or types of members.   A retail co-operative might have consumer members and worker members.  A co-operative daycare would have parent members, worker members and perhaps a community member.  An educational co-operative membership can include students, parents and teachers.  The idea is to have membership open to people for whom the co-operative was important and for all the members to share common goals.  As in every co-operative, each member would have one vote.  Each class of members would elect a portion of the board of directors.  All those for whom the co-operative was important would have a say in governance.

For eldercare homes one class of members would be the elder residents themselves, healthcare worker members and family members where the family had a loved one who was a resident.    Each “class of member” would elect the members of the board of directors.  The eldercare workers might elect four board members, residents three, family members two.  Those nine might choose a director from the community or area served by the facility.  This structure would ensure that the policies and operations of the home were based on decisions made with input for whom the home was of major importance. 

The purposes of the co-operative would be: to provide an excellent level of care to elder residents; a rewarding place to work with fair pay and benefits as well as the opportunity for workers to be the best they could be; and to ensure open, clear communication to families that their loved one was well looked after and the assurance that they were well informed.   Let me suggest that this structure is much preferable to private for profit ownership.  If you review the lessons learned from the COVID 19 elder care disaster, this organizational structure has enormous promise.

• It gives those elders involved a role of participation and respect and a voice in governance.  Their wisdom and the contribution they have made and can still give are given an outlet.  Their dignity as humans is respected by giving it voice. 
• A solidarity co-operative structure demonstrates respect for the care givers and those workers who put their lives, and often the lives of their families, on the line during a crisis.  Behavioural economics tells us, that given a living income, a sense of workplace autonomy, the chance to be the best you can be and the opportunity to make the world a better place are all stronger motives than financial gain.  We put signs in our windows, stood on balconies and cheered and sung and banged pots and pans; now is the time to make changes to show we really do care and admire them.   
• It responds to the pain of families whose hearts were broken as they learned their loved ones whom they had been unable to see, had died in a world that did not even allow normal grieving or a funeral.  It responds to the horror of those who learned those they loved had died filthy and of hunger or dehydration. 
• It is an organizational structure that allows elders, their families and the elder care workers to regain trust in elder care facilities.
• It makes the role of governments to regulate standards of care much more easily achievable.
• It encourages working together with other eldercare co-operatives to communicate with government and the community about elder care needs and issues.  Clearly organized voices offer a great improvement over the past inability of the warnings of individual elder care advocates to be heard.  Not hearing or acting on those warnings allowed the eldercare disaster to evolve.

The Role of Government

It is clear to Canadians that our policies toward elder care and the elder care providers has been an appalling failure.  Last year Ontario and Quebec cut healthcare funding by over a half a billion dollars.   Atlantic Canadians have faced doctor shortages for over 25 years with an estimated 9-13% of Atlantic Canadians lacking a family doctor.  In Nova Scotia the closure of emergency rooms exploded from just over 20,000 hours in 2014-15 to just under 50,000 in 2018-19, and the waiting list for elder care is, sadly, large and long.  The Nova Scotia government priority has been a balanced budget. 

In reality, between 2008 and 2019, the share of the world’s wealth in the hands of the richest 1% has climbed from 42% to over 50%.  The claims of neoclassical economics that richly rewarding the already very rich would result in a ‘trickle down’ of wealth to the 99% has in reality fueled a ‘trickle up’, or more correctly a flood of wealth to the 1%.  The rich threaten that if we do not cut their personal and corporate taxes they will take their money to another country and leave us jobless.  But even with cut taxes, they pull their money out and hide it in tax havens.  We have clearly hung on far too long to the bizarre notion that an economy guided by greed and self-interest would not have terrible consequences.  

We are solidly in the midst of a new epoch in the history of our planet, ‘The Anthropocene’.  It is an era in which it is impossible to look at any location on our planet without finding it being reshaped by human activity.  It is a period in which humans may well choose to largely destroy the ability of the planet to support life as we know it, a process which has already begun.   We are, in terms of geologic time, speeding toward runaway climate change.  The sixth mass extinction of life on the planet is now happening.  We have made the air toxic.  We have made the oceans increasingly acidic, choking in plastic and subject to a reduction in life.  We are heading for a global fresh water shortage.  Worldwide epidemics have increased from 3 in the 1800’s, 5 in the 1900’s and 5 since 2000, in just 20 years.  Our investor based economy will do anything that produces a profit.  Capital has become the modern god for whom no sacrifice seems too great.  It is evident in our approach to eldercare.  Nature and society are organized in the service of capital and insatiable greed.

COVID 19 and climate change are urgent calls for us to shift to a human economy focused on meeting human need, one governed fully recognizing our interdependence with nature and each other.  Sadly, it is possible that the response to both will be to tax the 99% to bail out the 1% who do not need it.   That was the response to the 2008 economic collapse caused by financial industry greed.  It is the COVID 19 response of the Trump administration in the United States for whom we walk on egg shells to avoid offending.  It is possible our governments will pour billions of dollars more into the oil industry attempting to return to the 1950’s.  It may bail out companies with trillions of tax dollars without taking a strong ownership position or control on behalf of tax payers whose money they invested.   Or we can start the careful process of building a green democratic economy.  If we absolutely must bail some corporations out the government should own them and sell them to their workers to run co-operatively.

If we pick a long term green economic democracy approach, there is no better place to start than with elder care using strong measures to nurture, support and finance a co-operative, participatory, people based approach.  Post COVID 19 federal and provincial governments need to decide to raise revenues by dealing with getting the richest 10% of Canadians to pay their fair share.  This would strengthen provincial revenues and make possible federal transfers to provincial governments with a strong bias for solidarity elder care co-operatives.  Engage the co-operative sector and credit unions.  Let us build elder care with Canadians, engaging the best of who they are rather than having them ill served by facilities built for other purposes.