At the peak of the second wave of the coronavirus in Israel, on the eve of the Rosh Hashanah holiday, some people came to work despite having tested positive for the virus. They did it with the Health Ministry’s blessing, even though their jobs entailed caring for the population most vulnerable to the virus’s ravages, older adults in nursing homes.
Prof. Nimrod Maimon, head of the Health Ministry team charged with protecting Israel’s institutionalized old people, admits as much. The infected workers were caring for patients who had themselves tested positive, so there was no risk of further infection within the institution. But what about the risk inherent in sick people commuting to and from work?
Maimon doesn’t defend that decision, nor one to permit employees who were exposed to a confirmed coronavirus carrier, and thus required to self-isolate, to continue working. Both were calculated risks taken at the peak of a crisis. In place of quarantining, these employees continued to work but did a coronavirus test every three days to verify that they were not infected.
Clearly the ministry would not have permitted this arrangement for any other workers, yet those caring for the country’s most vulnerable people were sent to work while sick or at risk of infection. There was simply no choice, given the massive personnel shortage in Israeli old-age homes.
A country’s success in managing the pandemic can be measured by the weakest link. In this case, there’s no question that it’s nursing homes. Some 104,000 people live in old-age homes in Israel. Some are fully independent individuals who chose to live in a social environment, while others are fully dependent on nursing care. The 60,000 workers caring for them are among Israel’s most disempowered – foreign workers, Palestinians, Arab-Israelis and new immigrants, and the pay and working conditions reflect this. The jobs are not desirable ones, and the working conditions are tough.
These are the workers on the front lines in the war against the pandemic, given the massive risk of outbreaks within old age homes. Statistics from around the world indicate that old-age homes were the site of some of the worst outbreaks. Some 80% of coronavirus deaths in Canada were in old-age homes, and in Germany the figure was 50%, says Maimon.
Israel lost control of the virus in nursing homes during the first wave, when some two-thirds of all fatalities were nursing home residents. In the second wave, they again accounted for half to two-thirds of deaths. These are massive numbers, even if Maimon says they reflect a certain success.
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The nonprofit Veshamarta, which assisted nursing homes during the first wave before the Health Ministry formed its team to protect older adults, examined how institutions handled the second wave. The research, conducted in partnership with the Gertner Institute’s Epidemiology Division, did not produce flattering findings.
Infection rates at care institutions were as high as 8%-10%, versus 1.6% among people 65 and up who live independently. The mortality rate for old people in institutions was very high, averaging 20% of those infected. On average, 10 people per care institution were infected. The outbreaks were caused by infected workers; some 1,000 workers tested positive during the second wave.
However, there was some improvement from the first wave. While the number of old people living independently who were infected was nine times higher in the second wave than in the first, it was only six times higher within care institutions. Within the first wave, an average of five residents were infected for every infected staff member; by the second wave it was three residents for every one infected staff member. This was due to the Health Ministry’s plan to protect nursing homes. The attempt to divide workers into isolated units didn’t work, primarily due to the chronic lack of manpower.
The protection relied on two main strategies. The first was maintaining basic hygiene, primarily by wearing masks and frequent handwashing. The second, more important strategy was the massive testing of employees. All 60,000 workers in institutions for old people, including retirement communities, were tested at least once a week. At the peak of the second wave that rose to twice a week. Whenever a worker tested positive, all the residents at the home were tested as well.
The huge testing volume made it possible to identify infected workers quickly and then to test all the people they cared for in order to isolate subsequent infections. Thus chains of infection were intercepted quickly. Given that infection within old age homes almost certainly means death, the high testing volume was a critical means of defense.
But it’s a defense that’s not without criticism. The cost of conducting 12,000-19,000 tests a day just in geriatric institutions is quite high. Veshamarta says some of these tests were conducted at retirement communities even though they were not the site of many infections. The nonprofit recommended that these tests be used at nursing homes instead, a recommendation that angers Maimon.
Veshamarta highlights other aspects of quality of life at nursing homes, particularly given the fact that family visits have been banned. Veshamarta found that a large percentage of institutionalized elderly suffered from anxiety or depression even if they weren’t infected by the virus, and their health and cognitive function declined.
The national response may have protected the institutionalized elderly from the coronavirus, but it killed them from isolation. Therefore, Veshamarta is pushing for a policy that enables regular visits from family members. “For 2 million shekels [$592,000], protected visitation facilities could be set up for all the institutions,” says Veshamarta CEO Ronen Goldstein. “This will save elderly citizens’ lives.”
There’s no debate regarding that recommendation, but it, too, runs into personnel limitations, as there aren’t enough workers who could facilitate family meetings. The lack of personnel is what forced Maimon to bend all the rules, and permit employees to continue coming to work even if they were sick or otherwise obligated to self-isolate. Everyone agrees that there’s a shortage of workers, but the dispute is over the solution: Import more foreign workers, or create a national program to employ Israelis as care workers?
Veshamarta, too, acknowledges that the response at nursing institutions was much better during the second wave during the first, but warns of burnout at the institutions or among employees. “It’s a thankless task,” says Maimon. “In any case we’re going to lose here, but the question is whether we lose 7-0 or 2-1. The second wave was a 2-1 loss. We acquitted ourselves honorably.”