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By Matina Stevis-Gridneff, Matt Apuzzo and Monika Pronczuk
Photographs through Mauricio Lima
For years, warnings had accumulated that retirement homes were vulnerable. The pandemic sent them to the end of the line for gadgets and attention.
BRUSSELS – Shirley Dean sold out. The Christalain retirement home, which he ran with his brother in a prosperous domination of Brussels, in the process of making way for Covid-19. Eight citizens died in three weeks. Some staff members only had Halloween doctor’s gowns and goggles to protect themselves.
Help wasn’t coming either. Dean had begged hospitals for his inflamed residents. They refused. Sometimes he was told to administer morphine and let death come. Once, he was told to pray.
Then, in the early morning of April 10, everything was worse.
First, a resident died at 1:20 a.m. Three hours later, he died. At 5:30, one o’ll. The afternoon nurse had long stopped calling the ambulances.
Ms. Dean arrived later and learned that 89-year-old Addolorata Balducci was suffering from Covid-19. Ms. Balducci’s son, Franco Pacchioli, demanded that paramedics be called and pleaded with them to take their mother to the hospital. Instead, they gave him morphine.
“Your mom will die,” the paramedics replied, Pacchioli recalled. I said, “That’s it.”
The paramedics are gone. Eight hours later, Mrs. Balducci left.
Fugitive coronavirus infections, a shortage of medical devices and a lack of government care are extraordinarily familiar stories in nursing homes around the world. But Belgium’s reaction takes a terrible turn: paramedics and hospitals categorically reject care for the elderly, even if hospital beds are not used.
Weeks earlier, the virus had hit Italian hospitals. Determined to prevent this from collapsing in Belgium, the government has avoided and almost ignored retirement homes. But while Italian doctors said they had been forced to ration the care of the elderly due to a lack of area and equipment, the Belgian hospital’s formula has never been subjected to similar stresses.
Even at the height of the epidemic in April, when Ms. Balducci refused, the extensive care beds were not filled by more than 55%.
“They wouldn’t settle for the elders,” Dean said. “They had an area and they didn’t need it.”
Belgium now has, through some measures, the coronavirus mortality rate in the world, partly due to retirement homes. More than 5,700 retirement home citizens have died, according to recently published data. At the height of the crisis, from March to mid-May, citizens accounted for two out of three coronavirus deaths.
Of all the missteps of governments during the coronavirus pandemic, few have had as quick and devastating an effect on retirement homes as non-protective. Tens of thousands of older people have died, not only victims of the virus, but also more than a decade of ignored warnings that nursing homes were vulnerable.
Public fitness around the world has excluded nursing homes from their pandemic preparedness plans and overlooked citizens of the mathematical models used to consult their responses.
In recent months, the coronavirus epidemic in the United States has dominated global attention as the world’s richest country makes its way to the world’s highest death toll. About 40 percent of these deaths were similar to those in long-term care facilities. But even now, European countries are leading the world in terms of die-consistent with the capita, partly because of what happened in their nursing homes.
Spanish prosecutors are investigating which citizens died in. In Sweden, overworked emergency doctors admitted rejecting elderly patients.
In Britain, the government has ordered thousands of elderly hospitalized patients, some with Covid-19, to return to nursing homes to make way for an expected drop in virus cases. (Similar policies existed in some U.S. states.)
But by focusing on rescuing their hospitals, European leaders have left citizens and staff in nursing homes to their fate.
“We thought about it and said, “Retirement houses are important,” Matt Keeling, a British emergency adviser, recently testified. “We thought they were protected, and we probably thought about it enough.”
That’s not the case. Only about a third of European nursing homes had infectious disease groups before the Covid-19 pandemic. Most had no inpatients and many had no outpatient arrangements to coordinate care.
Few countries include this reaction to a fatal and useless pandemic than Belgium, where the government has excluded patients from nursing homes from detection policy until thousands have already died. The old houses were left waiting for masks and proper dresses. When the government mask arrived, it came late and defective.
“Stick your mask on the edge of your nose,” regional fitness officials said in an email.
An executive at a nursing home, with no options, ordered thousands of ponchos after watching animal keepers take them to a rural zoo. Another controlled space to download 5,000 masks from a member’s father in Vietnam. The valuable shipment came through the diplomatic suitcase of the embassy.
Belgian officials say denying the care of the elderly has never been their policy. But in the absence of a national strategy, and with regional officials arguing over who is in charge, officials now recognize that some hospitals and emergency services have relied on indistinct recommendations and direction to do just that.
The scenario was so terrible that the charity Doctors Without Borders sent more accustomed expert groups to run in war-hardened countries. On 25 March, when a team arrived in Val des Fleurs, a public retirement home a few kilometres from the European Union headquarters, they were greeted with a mild smell of disinfectant and immobility, only pierced by the singing of a caged canary.
Seventeen more people have died there in the last 10 days. There’s no protective equipment. Low oxygen. Half the staff were infected. Others showed symptoms of trauma that were not unusual in the affected areas, concluded by a psychologist at the medical arrangement.
The director and her deputy were in poor health for Covid-19, and the acting leader collapsed into a chair crying as soon as the team met her.
“I never thought I was going to paint with M.S.F. in my own country. That’s crazy. We are a country,” said Marine Tondeur, a Belgian nurse who has painted in South Sudan and Haiti.
Ms. Tondeur was horrified by her country’s response.
“I’m a little embarrassed, in fact, to have forgotten those houses.
In February, when the coronavirus took root in northern Italy, Belgian officials gave few warnings. Maggie De Block, Belgium’s federal health minister, spent the month minimizing the risk. She saw a desire to worry about hospital capacity or testing capabilities.
“It’s not a very competitive virus. You’d have to sneeze in someone’s face to transmit it,” he said on March 3, adding, “If the temperature goes up, it will go away.”
Even after the World Health Organization pressed the importance of creating plans to protect nursing homes, a spokesman for the dutch-speaking Belgian fitness authority said there is no explanation for why to worry.
“The infection rate is very low right now,” he said.
However, the precautionary symptoms were there. Belgium has one of the largest populations of care homes per capita in the world, and years of studies have shown that respiratory diseases such as Covid-19 are among the most common diseases in these facilities. Data from China showed that other older people were exposed to Covid-19 as much as possible.
Government reports from 2006 called for infectious disease education for nursing doctors and public assistance to purchase protective equipment. A separate report in 2009 adding nursing homes to the national pandemic plan. The two proposals were nowhere to be made.
In early March, for example, nursing homes were quite self-sufficient. Belgium’s internal threat assessment documents even mentioned nursing homes as one of the main concerns.
“We have won any express recommendation from ministers,” the Femarbel Nursing Home Association wrote to its members.
Around the world, nursing homes operate on the brink of local, regional and national surveillance, but Belgium is expanding this problem. Divided by language and difficult to govern, Belgium has so many degrees of bureaucracy that it is rarely known as administrative lasagna.
The country still has one still nine fitness ministers, who respond to six parliaments. The federal government plays a coordinating role in the event of a pandemic, however, nursing homes are a duty of regional authorities.
Therefore, even when officials learn of the risk posed by Covid-19, they can act decisively.
“We need several weeks to know who was responsible,” said Pedro Facón, a senior federal fitness official this month.
In mid-March, as coronavirus spreads rapidly, regional governments presented recommendations to nursing homes, but this is not useful on key issues. Government documents have under pressure the importance of masks, while pointing out that they are not available.
“There’s practically no mask available on the market,” one document says. Caregivers were begged to reuse the mask, hide it from administrative staff, and search nearby hospitals for appliances.
And they did. At Christalain House, Steve Doyen, Ms. Dean’s co-owner and brother, said he discovered a handful of blouses and glasses thanks to a friend who liked to dress up as a Doctor for Halloween.
To aggravate the problem, Belgium was unable to control even a fraction of those infected. Therefore, the fitness government should monitor hospitalized and critically ill patients. We told everyone to pick up the house.
This meant leaving other people contagious in overcrowded nursing homes, with little staff and little equipment.
“From the beginning we felt like we were going the other way around,” said Lesley Moreels, director of a public retirement home in Brussels. “We felt becoming firefighters in their pajamas.”
Belgium entered the lockout on 18 March. Dozens of retirement home citizens had already died. Three days later, Jacqueline Van Peteghem, a 91-year-old Resident of Christalain House, was sent to UZ Brussel, a nearby hospital, where she checked if she had Covid-19. Within a few days, his check turned out positive.
Shirley and Steve Dean assumed that Ms. Van Peteghem would remain hospitalized for treatment and prevent the disease from spreading to dozens of other residents. But her symptoms had stabilized and Mr. Dean said a doctor at the hospital had declared her healthy enough to return home.
For example, on 27 March, paramedics dressed in cover jumpsuits of dangerous fabrics took Ms. Van Peteghem on a stretcher to Christalain’s door.
Mr. Dean greeted them with a surgical mask.
“Is this all you’ve got?” Paramedics asked, Dean recalled.
“Yes, ” he said.
“Good luck, ” they answered.
Over the next hour, Christalain’s staff watched the paramedics decontaminate themselves and their ambulances. When asked later about hospital policies, the director general, Professor Marc Noppen, said that infectious patients were not sent back to nursing homes, but that this may have happened in some cases.
No one can be sure that Ms. Van Peteghem’s return was the reason, however, Covid-19 infections in the house have increased. Residents began to die. Ms. Van Peteghem, who first survived the virus, died last month.
The Belgian government was aware of the problems, according to internal documents. “Some patients have returned infected from the hospital,” a government emergency committee wrote on March 25. “Several hot spots were this way.”
The committee recommended testing citizens of nursing homes and building sites to space out Covid-19 patients who would be sent home in a different way.
But the national and regional government can agree with those recommendations and the country remained a mix of policy.
For another two weeks, even as the government expanded its detection capacity, fitness advisers resisted adding nursing homes to the national precedence checklist. They participated that even the new capacity would not be to meet the call according to the extended criteria, according to documents and government officials.
“The federal government has conducted some tests. Hospitals had evidence,” said Dr. Emmanuel André, a virologist who decided as a government adviser and advocated for broader federal evidence. “But retirement homes? No tests were allowed.”
As an interim measure, Philippe De Backer, a minister who had been asked to expand checks, introduced a first batch of checks to retirement homes in early April. But he and others sought to have the citizens officially added to the precedence checklist. Support for this replacement still merged on April 8. Mr. De Backer participated in a convention of the government threat control organization, one of the many committees that explained the policy in Belgium.
“You can avoid the debate,” he said. “We in nursing homes.”
When the first effects were announced, one in five citizens tested positive. By that time, more than 2,000 more people had already died.
As the debate about the tests took place last March and early April, hospitals stopped bringing inflamed patients to nursing homes in silence.
The officially only recommendation policy is reflected in a series of memorandums by Belgian geriatric specialists.
“Unnecessary transfers are for paramedics and emergency rooms,” reads in an initial memorandum signed through the Belgian Society of Gerontology and Geriatrics and two primary hospitals.
Extremely fragile and terminally ill patients receive palliative care and are not hospitalized, the memo says. The document provided a complex organization chart to decide when to hospitalize nursing home residents.
The gerontology corporation says that its recommendation, written in case the hospital’s formula overflows, has been misunderstood. The company is a government agency, doctors and, and never intended to deny hospital care to the elderly.
But that’s what happened.
On the morning of April 9, Dr. André, the government’s pass-through adviser, was preparing for the daily press conference when a question, asked through a journalist, surprised him: would the citizens of the residences soon be allowed to go to the hospital?
“Why is this coming?” Dr. André remembers thinking. “Yes, of course you can.”
But on many occasions, citizens of nursing homes with Covid-19 symptoms were denied hospitalization, even when they were derived through doctors who felt they could recover.
“The resolve not to settle for citizens in hospitals surprised me,” said Michel Hanset, a doctor in Brussels who tried unsuccessfully to admit several patients to nursing homes.
It is not known how this happened, however Doctors Without Borders says that about 30% of the families they worked on during their deployment reported this problem.
Government figures are also revealing. In the first weeks of the crisis, nearly two-thirds of the deaths of elderly villagers occurred in hospitals. But as the crisis worsened and geriatric memoris began to circulate, that number declined.
At the height of the epidemic, only 14% of critically ill citizens went to the hospital. The others died in their retirement homes, according to the knowledge of the government compiled through Belgian scientists and published in the New York Times.
It’s knowing how many deaths have been avoided. But the hospitals still had space. Even at the height of the pandemic, 1,100 of the country’s 2,400 beds of extensive care were free, according to Niel Hens, government adviser and professor at the University of Antwerp.
“Paramedics had been told through their reference hospital not to accept patients over a certain age, 75 but infrequently only 65 years old,” Doctors Without Borders said in a July report.
Some senior regional and national officials have this problem.
“I heard at the nursing home who arrived in emergency doctors, took the citizens and then sent them back to the nursing homes, saying they couldn’t leave them in the hospital,” said Christie Morreale, director of fitness in Wallonia, Belgium. – language region, he said in an interview.
Ms. De Block, National Minister of Health, refused to be interviewed and did not answer written questions. In interviews, the hospital’s top doctors defended their policies. They said the staff at the nursing home was for the hospital care of terminally ill patients who needed to be comforted in death, not dragged into the hospital.
The case that elderly villagers were denied admission, they say, was due to a doctor’s decision that they were unlikely to survive.
“If you think the medical remedy is favorable for this patient, you will be hospitalized,” said Professor Noppen, director of UZ Brussel. “It’s as undeniable as that.”
Nursing home managers insist that this is not the case.
“At one point, there was an implicit age limit,” said Marijke Verboven of the Orpea Group, which owns 60 houses in Belgium.
Mr. Moreels, whose nursing home, Val des Roses, also benefited from an intervention through a team of Doctors Without Borders, agrees. “The ambulance didn’t take them,” he said. “There was no detailed consultation. They just said, “Why did you call us?”
The Brussels Ambulance Service has denied any policy of refusing to take nursing citizens to the hospital. However, even some doctors are skeptical.
“We learned that other people in nursing homes think it’s not even worth calling an ambulance,” said Dr Charlotte Martin, lead epidemiologist at St. Peter’s Hospital in central Brussels. “They were the first to enter the pipe. And instead, they were simply forgotten.
At Christalain House, activities resumed this summer and life came closer to normal. But there is a shadow left: 14 citizens have been shown to have died of Covid-19. Another, devastated and overly forty years old, committed suicide in April.
Pacchioli, whose mother died after being denied hospitalization, is obsessed with a question. “Maybe it wasn’t too late, ” he said. “If I had gone to the hospital, I would have survived.
The Médecins Sans Frontis groups completed their missions in nursing homes in Belgium in mid-June. Some members have returned to emerging countries. Others are now running in a crisis-rich country: the United States.
Today, Ms. De Block, Belgium’s national fitness minister, talks about nursing homes as if it were an unfortunate footnote in the history of a successful government response. Note with pride that Belgium has never run out of hospital beds.
“We took action at the time,” he said in an interview, adding, “We can be proud.”
The reports were through David Kirkpatrick and Selam Gebrekidan in London, Julia Echikson and Koba Ryckewaert in Brussels and Christina Anderson in Stockholm.
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