Betrayal of Trust? The Impact of the COVID-19 Global Pandemic on Older Persons
Eldre personer og personer med alvorlige underliggende medisinske tilstander ser ut til å ha større risiko for å utvikle mer alvorlige komplikasjoner fra COVID-19. Disse trenger ressurskrevende medisinske inngrep når de først er smittet. Utfordringen er at det ikke finnes tilstrekkelig medisinsk bemanning og utstyr til å hjelpe dem. Hvordan prioriterer vi under moralske, etiske og politiske dilemmaer? Blir vi diskriminerende når det er ubalanse mellom tilbud og etterspørsel?
In a 2001 book review of Laurie Garrett’s “Betrayal of Trust: The Collapse of Global Public Health,” Dr Amir Attaran, the then Director of International Health Research at Harvard, referred to the content as the “stuff of nightmares” (Attaran, 2001). In her book, Garrett warns of profound vulnerabilities across the network of public health arrangements, medical institutions, and political infrastructure that could lead to the rapid spread of a future nefarious virus with devastating consequences (Garrett, 2000). Now, some two decades later, many of those forewarnings have come to pass as countries around the world attempt to control the spread of the novel coronavirus (COVID-19). In the devastating 3 months since first reports of people presenting with symptoms in China to the devastating events unraveling in places such as Bergamo (Italy) and New York City (USA), the COVID-19 pandemic has, as of April 6, 2020, spread to more than 200 countries, infected more than 2.7 million people, and taken more than 187,000 lives (World Health Organization [WHO], 2020).
The complete landscape of COVID-19’s clinical presentation is emerging, but not yet fully understood. Similar to other pathogens within the coronavirus family, COVID-19 targets the respiratory system (Rothan & Byrareddy, 2020). New evidence is emerging, to suggest that COVID-19 may also affect the nervous and cardiac systems thereby obscuring how to effectively manage the disease process (Guo et al., 2020; Wu et al., 2020). The Centers for Disease Control and Prevention (CDC, 2020) report that after a 2- to 14-day incubation period, symptomatic infected persons generally present with cough, fever, myalgia, and shortness of breath. Once infected, a person can experience a range of disease severity, from someone being fully asymptomatic through to someone fighting for their lives in a high acuity setting on a ventilator.
According to the WHO-Europe, 95% of COVID-19 deaths are among people older than 60 years, and further, 50% of all deaths are among people 80 years and older (Lardieri, 2020; WHO Regional Office for Europe, 2020). Using an Italian and Chinese sample, Onder and colleagues (2020) reported an overall case fatality rate of 7.2%, with fatality rates between 0.3% and 0.4% for the 30- to 49-year group, between 1.0% and 3.5% for the 50- to 69-year group, and between 12.8% and 20.2% for those aged 70 years and above. While others have reported lower aggregated case fatality rates (Mahase, 2020; Porcheddu et al., 2020; Singhal, 2020), they all consistently report a concerning trend toward higher fatality rates among older age groups. The CDC report on their website that “Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness” (CDC, 2020). Overall, it has become rather clear that older persons, especially those who have underlying chronic health conditions, are at greater risk of contracting and experiencing serious illness with COVID-19 (Zhou et al., 2020).
Not all older persons will contract COVID-19 thereby creating, for the purposes of our argument and for simplicity, two possible theoretical groups. First, a group of older persons who will acquire the virus and will struggle through the disease trajectory and second, a group who will not acquire the disease, but who will spend the next number of months under crushing isolation and under a great deal of stress and uncertainty. While the trajectory for each group differs, each could have rather monumental consequential outcomes, all of which could largely be mediated with appropriate early supportive interventions.
First, consider the group of older persons who will acquire the disease. Based on global trends, they are very likely to require resource-intensive medical interventions, once infected. The challenge is that there may not be sufficient medical staffing or equipment supply to meet the surge of demand. The high infection and mortality rates among older persons, relative to younger populations, have ignited equity debates surrounding decision-making and allocation of scarce resources required for survival (Nakazawa et al., 2020; Rosenbaum, 2020; White & Lo, 2020). For instance, in overcrowded hospitals where enormous imbalances of supply and demand exist, the burden of complex emergency medical decision-making creates important moral, ethical, and political dilemmas. Under those conditions, there are pronounced risks for allocation of scare resources to be done in discriminatory ways (Fink, 2020; HelpAge International, 2020). To standardize complex allocation decisions, and to guard against explicit discrimination, White and Lo (2020) established an explicit, accountable, and transparent allocation framework that can be used to allocate intensive care beds and ventilators during the COVID-19 pandemic that does not discriminate based on age. While we fully appreciate that disaster and emergency pandemic medicine engenders the need to reallocate scarce resources, we also believe that even consideration of basing resource allocation decisions on age would be socially and morally regressive. Nevertheless, recent media reports of older people giving up their ventilators, or speculations that older person should do everything to save a younger person’s life, has fed into the narrative that older persons have less value (Rodriguez, 2020; Wray, 2020).
The second group comprises older persons who will not contract the disease, but who are now socially and physically isolated. The global population is now encouraged, and in some countries legally and militarily forced, to engage in self-isolation to reduce the spread of the virus and to flatten the curve in the rate of new cases. Such public health measures are designed and implemented to protect the entire population, but given their higher risk of contracting COVID-19, older persons have been even more strongly advised to isolate to reduce their exposure. Paradoxically, even though these measures are meant to protect, we contend that they may have unintended negative consequences on segments of older persons. For instance, frail home-dwelling older persons who rely on home-based care for survival are likely to receive fewer home visits, which in turn will negatively influence their health or functional level. Other older persons living fully independently or living in supportive institutions are also likely to experience reduced levels of activity, which can exert important negative long-term consequences. Physical movement must be a core activity in older persons’ everyday life to optimize independence and mental health (Tuntland et al., 2019) and being confined under greater isolation presents a high risk of functional decline from the isolation (that paradoxically is meant to protect them). Healthy aging-in-place is seen as enabling people to maintain independence, autonomy, and connection to social support (Wiles et al., 2012). Although, in the times of the COVID-19 pandemic, “unhealthy” aging-in-place seems to be emerging and we are concerned that the long-term outcomes could be devastating for older persons in this group.
Overall, we highlight that the impact of emergency triage decisions and robust public health preventive measures during this pandemic may exert a disproportionate impact on older persons. We signal that even in challenging times such as these, dignity and rights of older people must, and can, be preserved. To optimize physical and mental health of older persons during these moments of extreme restrictions, we argue that public health measures to control the pandemic should be accompanied and balanced with supportive programs that will protect older persons from physical and mental decline. To avoid “betrayal of trust” in the times of pandemic, we must protect older people’s rights, on one hand, by ensuring that the allocation of scarce life-saving resources is solely based on clinical judgments and not fueled by ageism, stereotypes, and biases, and on the other hand, by providing safe, innovative, and accessible supportive services that will help older people maintain their physical and mental health.