QUESTIONS FOR André Picard
The Globe and Mail ’s health expert talks about reimagining elder care — and why COVID-19 is just a practice run.
You have said that no group in society has been more profoundly neglected for an extended period of time than our elders. Please describe the current state of affairs.
We live in an aging society, and yet it’s a society that doesn’t respect its elders. In Canada, we tend to value economic contributions above all else, so once you retire, you are viewed as a cost to the system. It’s almost like you’re disposable, and that is evident in the way we treat people who get really sick: We institutionalize them — hiding them away, out of sight and out of mind. There is profound ageism ingrained in both our social policies and our attitudes.
In its pre-pandemic report, the Public Inquiry Into the Safety and Security of Residents in Long-term Care Homes pointed to “systemic vulnerabilities” as the root of failings in this sector. How would you summarize these vulnerabilities?
I mentioned the widespread marginalization of older people, and nowhere is that more obvious than in long-term care. About 400,000 older Canadians live in these facilities, and while there are some good ones, most are not great places to live. Many are grossly understaffed, and the staff they do have are poorly paid, so turnover is high. There is poor infrastructure, too. Lots of these homes are old and poorly designed, so people often live in rooms with three or four beds, in almost prison-like conditions.
Another fundamental systemic issue is the lack of choice. Most residents end up there by default, but they would much rather be at home. Although the care is being provided by hard-working, good people, it is very much task-based care rather than needs-based care. Caregivers simply don’t have the time to sit down and have a cup of tea with a resident who they know is lonely. And as any
physician will tell you, that is just as important as changing a resident’s wound dressing or making sure they get to the bathroom safely.
Describe the role of more widespread home care in addressing some of these issues.
It’s not a panacea, but home care is important. Some people need assisted living, but we need to give those who can choose some input about where they live, and provide them with the required support to make these decisions.
Keeping people in the community should be a priority, both politically and health-wise. In Canada, our universal health system is something we cherish, but it should not just be about covering hospital care when we get sick. It should also include the provision of drugs, long-term care when needed, and home care where possible.
Of course, if an individual chooses homecare, they should make a contribution towards it; the public system can’t cover 100 per cent of our needs. But already, people are paying a lot for long-term care: The bare minimum — if you have any savings at all in the bank — is about $3,000 per month, and it goes up to $15,000 a month or more. We forget what an economic burden this is for families.
Many people believe home care would be even more expensive, but that’s not true. If you provide care smartly, efficiently, and give family caregivers some support, it doesn’t need to be any more expensive than long-term care. If money is the primary concern — and I don’t think it should be, but if it is — then we could set up a rule like some countries have, where people can put government funds towards their home care to the equivalent of current long-term care prices. Once they hit the maximum, they are forced to make a decision: Either pay more out-of-pocket or move into a facility. Just by doing this, we could get nearly half of residents out of institutional care. It all comes down to choices.
Is there a country on the planet that has gotten this right ?
Denmark is the gold standard for its treatment of elders. Back in the 1980s, they recognized that they were dealing with an aging population, and they wanted to treat these citizens with respect. So, they made a public policy commitment that everyone who wants to remain in the community can do so, and they created policies to enable that. They do have some long-term care homes, but they’re small and very home-like — not these 200-bed, prison-like institutions we have in Canada. Clearly, if you make this a priority, it is doable. When you visit Copenhagen, you often see 90-year-olds riding their bikes around the city. They have made a societal choice to value older people just as much as young people.
Describe the key principles of your ‘rough blueprint’ for fixing eldercare in Canada.
Above all else, we need to start valuing our elders. They are as important as everyone else and they should be made to feel part of our society. That’s the big overarching principle. Second, we need to provide people with the right care at the right place at the right time. We have to put an end to the notion that when older people get sick, we can just stick them in an institution. We need to find a way to support people where they live. Those who want to should live in the community until the last possible moment — and then, when they definitely need assistance, it should be provided in a an attractive, home-like environment.
I worry when I hear politicians saying, ‘We can solve this by adding more beds’. That would be the worst possible outcome, because we don’t need more mediocre care: we need better care. We have to rebuild the system pretty fundamentally. And we can’t forget that the vast majority of our elders — about 90 per cent of them — actually live in the community already. They are living in their homes or apartments, and we have to make that not only bearable, but enjoyable. We need to subsidize housing for our elders, and increase home care, as indicated. We also need community services that ensure people aren’t living in isolation and poverty. Overall, this has to become a vast societal project. People deserve to have a good life, right until the very end.
With respect to the restrictions enacted to combat COVID-19, many have argued that ‘the cure is worse than the disease’. What is your view?
I think the notion that we can either protect the economy or protect people’s health is a false dichotomy. The reality is, we can’t have a healthy economy while there is a pandemic raging, and nor can we have a healthy economy if people are living in fear. Yes, there has been some harsh medicine imposed, and it has many costs. But the alternative — doing nothing — would have been much more costly.
We need to give those who can choose some input about where they live.
There will be a lot of fallout from this pandemic. There will be widespread mental-health issues, and we will need to catch up on all the delayed surgeries. There will also be untold economic losses and a vast debt burden that will impact what we fund in our society going forward.
As we speak, vaccines are rolling out across Canada. Are you on board with the approach taken thus far?
The vaccine is our great hope to get out of this mess sooner rather than later. It’s not the only tool we have, but it is an important one. I think Canada has done some things very well, and other things poorly — like every other country.
Our key problem is that we were very slow to order vaccines. I don’t think anyone imagined that we would have such dramatic scientific breakthroughs so quickly. Receiving vaccines in less than a year was simply unthinkable, so Canada dragged its feet and didn’t place orders early on. The government tried to make up for this by buying a lot of vaccines per capita — more than any country in the world. That part of the strategy is good — but because we were so slow at the outset, we have delays for the general public. I think realistically, most people will get their vaccine this summer, and when that happens, things will definitely start to take off in terms of regaining some sense of normalcy in our lives.
As a journalist, you have had a longstanding interest in the viruses, bacteria and parasites that have been the scourge of humanity since the dawn of time. Are we approaching a time when we can put these things behind us?
Quite the opposite. Given the way the world is evolving, I think we can expect more pandemics and threats. Increasingly, we live in close contact with wildlife, which is where these things come from. The Coronavirus emerged from bats, and the flu comes from our close interaction with livestock like pigs and chickens. These interactions will continue to create opportunities for new pathogens to arise.
We’ve been talking about viruses non-stop for the past year, but I believe our next big threat will be drug-resistant bacteria. Given the way our food production system operates, we can expect some significant food-borne illness outbreaks. This pandemic has been like a practice run. As bad as it has been, we forget that it could have been much, much worse.
People can have a good life, right until the very end.
Early in 2021, you wrote that this pandemic “will not end with a moment of triumph, but with a slow whimper”. Please explain.
People often use war analogies to talk about the pandemic, but there is not going to be a ceasefire at some point. Even if we do the best job with vaccinations, it’s going to take years to vaccinate the entire world, and there will be people who refuse it. We also don’t know if there will be any lasting side effects.
What we know from history is that pandemics tend to peter-out over time. People slowly build up immunity, they get used to living differently, and they adjust. It’s not going to be like the end of World War II, where everyone ran into the streets and hugged each other. We need to recognize that the consequences of this pandemic will be with us for a long time.