Warnings had piled up for years that nursing homes were vulnerable. The pandemic sent them to the back of the line for equipment and care.
BRUSSELS — Shirley Doyen was exhausted. The Christalain nursing home, which she ran with her brother in an affluent neighborhood in Brussels, was buckling from Covid-19. Eight residents had died in three weeks. Some staff members had only gowns and goggles from Halloween doctor costumes for protection.
Nor was help coming. Ms. Doyen had begged hospitals to collect her infected residents. They refused. Sometimes she was told to administer morphine and let death come. Once she was told to pray.
Then, in the early morning of April 10, it all got worse.
First, a resident died at 1:20 a.m. Three hours later, another died. At 5:30 a.m., still another. The night nurse had long since given up calling ambulances.
Ms. Doyen arrived after dawn and discovered Addolorata Balducci, 89, in distress from Covid-19. Ms. Balducci’s son, Franco Pacchioli, demanded that paramedics be called and begged them to take his mother to the hospital. Instead, they gave her morphine.
“Your mother will die,” the paramedics responded, Mr. Pacchioli recalled. “That’s it.”
The paramedics left. Eight hours later, Ms. Balducci died.
Runaway coronavirus infections, medical gear shortages and government inattention are woefully familiar stories in nursing homes around the globe. But Belgium’s response offers a gruesome twist: Paramedics and hospitals sometimes flatly denied care to elderly people, even as hospital beds sat unused.
Weeks earlier, the virus had overwhelmed hospitals in Italy. Determined to prevent that from happening in Belgium, the authorities shunned and all but ignored nursing homes. But while Italian doctors said they were forced to ration care to the elderly because of shortages of space and equipment, Belgium’s hospital system never came under similar strain.
Even at the height of the outbreak in April, when Ms. Balducci was turned away, intensive-care beds were no more than about 55 percent full.
“They wouldn’t accept old people,” Ms. Doyen said. “They had space, and they didn’t want them.”
Belgium now has, by some measures, the world’s highest coronavirus death rate, in part because of nursing homes. More than 5,700 nursing-home residents have died, according to newly published data. During the peak of the crisis, from March through mid-May, residents accounted for two out of every three coronavirus deaths.
Of all the missteps by governments during the coronavirus pandemic, few have had such an immediate and devastating impact as the failure to protect nursing homes. Tens of thousands of older people died — casualties not only of the virus, but of more than a decade of ignored warnings that nursing homes were vulnerable.
Public health officials around the world excluded nursing homes from their pandemic preparedness plans and omitted residents from the mathematical models used to guide their responses.
In recent months, the coronavirus outbreak in the United States has dominated global attention, as the world’s richest nation blundered its way into the world’s largest death toll. Some 40 percent of those fatalities have been linked to long-term-care facilities. But even now, European countries lead the world in per capita deaths, in part because of what happened inside their nursing homes.
In Britain, the government ordered thousands of older hospital patients — including some with Covid-19 — sent back to nursing homes to make room for an expected crush of virus cases. (Similar policies were in effect in some American states.)
But by fixating on saving their hospitals, European leaders sometimes left nursing-home residents and staff to fend for themselves.
“We thought about it, and we said, ‘Care homes are important,’” Matt Keeling, a British emergency adviser, testified recently. “We thought they were being shielded, and we probably thought that was enough.”
It wasn’t. Only about a third of European nursing homes had infectious-disease teams before the Covid-19 pandemic. Most lacked in-house doctors and many had no arrangements with outside physicians to coordinate care.
Few countries embody this lethally ineffective pandemic response more than Belgium, where government officials excluded nursing-home patients from the testing policy until thousands were already dead. Nursing homes were left waiting for proper masks and gowns. When masks did arrive from the government, they came late and were sometimes defective.
“Tape the masks to the bridge of your nose,” regional health officials advised in one email.
One nursing-home executive, bereft of options, ordered thousands of ponchos after seeing animal-keepers wearing them in a countryside zoo. Another home managed to get 5,000 masks from a staff member’s father in Vietnam. The precious cargo arrived through the embassy’s diplomatic pouch.
Belgian officials say denying care for the elderly was never their policy. But in the absence of a national strategy, and with regional officials bickering about who was in charge, officials now acknowledge that some hospitals and emergency responders relied on vague advice and guidelines to do just that.
The situation was so dire that the charity Médecins Sans Frontières dispatched teams of experts more accustomed to working in war-hardened countries. On March 25, when a team arrived at Val des Fleurs, a public nursing home a few miles from European Union headquarters, they were greeted by the stale smell of disinfectant and an eerie stillness, pierced only by the song of a caged canary.
Seventeen people had died there in the past 10 days. There was no protective equipment. Oxygen was running low. Half the staff was infected. Others showed signs of trauma common in disaster zones, a psychologist from the medical charity concluded.
The director and her deputy were sick with Covid-19, and the acting chief collapsed in a chair, crying, as soon as the team met her.
“I never thought I would work with M.S.F. in my own country. That’s crazy. We are a rich country,” said Marine Tondeur, a Belgian nurse who has worked in South Sudan and Haiti.
Ms. Tondeur was horrified at her country’s response.
“I feel a bit ashamed, actually, that we forgot those homes.”
‘Firefighters in Pajamas’
In February, as the coronavirus was taking root in northern Italy, Belgian officials expressed little alarm. Maggie De Block, Belgium’s federal health minister, spent the month playing down the risk. She saw no need to worry about hospital capacity or testing capabilities.
“It isn’t a very aggressive virus. You would have to sneeze in someone’s face to pass it on,” she said on March 3, adding, “If the temperature rises, it will probably disappear.”
Even after the World Health Organization highlighted the importance of creating plans to protect nursing homes, a spokesman for the health authority in Belgium’s Dutch-speaking region said there was no reason to worry.
“The risk of infection is very small for now,” he said.
Yet the warning signs were there. Belgium has one of the world’s largest nursing-home populations per capita, and years of research has shown that respiratory illnesses like Covid-19 are among the most common diseases in such facilities. Data from China demonstrated that the elderly were most at risk from Covid-19.
Government reports as far back as 2006 had called for infectious-disease training for nursing-home doctors and public help to stockpile protective equipment. A separate report in 2009 recommended adding nursing homes to the national pandemic plan. Both proposals went nowhere.
So, at the beginning of March, nursing homes were effectively on their own. Belgium’s internal risk-assessment documents did not even mention nursing homes among the top concerns.
“We have received no specific recommendations from the ministers,” the nursing-home association Femarbel wrote to its members.
Nursing homes around the world operate at the seams of local, regional and national oversight, but Belgium magnifies that problem. Divided by language and perpetually difficult to govern, Belgium has so many layers of bureaucracy that it is sometimes referred to as an administrative lasagna.
The country has not one but nine health ministers, who answer to six parliaments. The federal government takes a coordinating role in a pandemic, but nursing homes are the purview of regional authorities.
So even when officials realized the threat posed by Covid-19, they could not act decisively.
“We needed several weeks to figure out who was responsible,” Pedro Facon, a top federal health official, testified this month.
By the middle of March, with the coronavirus spreading rapidly, regional governments offered nursing homes advice — yet it was unhelpful on key points. Government documents stressed the importance of masks, while simultaneously declaring them all but unavailable.
“There are virtually no masks available on the market,” one document said. Caregivers were advised to reuse masks, withhold them from administrative staff members, and scrounge for gear from nearby hospitals.
And scrounge they did. At the Christalain home, Steve Doyen — the co-owner and Ms. Doyen’s brother — said he found a handful of gowns and goggles through a friend who liked dressing up as a doctor for Halloween.
Worsening the problem, Belgium was unable to test even a fraction of those infected. So the health authorities decided to test severely ill, hospitalized patients. Everyone else was told to recover at home.
That meant leaving contagious people inside crowded, understaffed, underequipped nursing homes.
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“We got the impression quite early on that we would take the back seat,” said Lesley Moreels, the director of a public nursing home in Brussels. “We felt that we were going to be firefighters in pajamas.”
Test, Return, Infect
Belgium went into lockdown on March 18. Dozens of nursing-home residents had already died. Three days later, Jacqueline Van Peteghem, a 91-year-old resident at the Christalain home, was sent to UZ Brussel, a nearby hospital, where she was tested for Covid-19. Within days, her test came back positive.
Shirley and Steve Doyen assumed Ms. Van Peteghem would remain hospitalized for treatment and to prevent the disease from spreading to scores of other residents. But her symptoms had stabilized, and Mr. Doyen said that a hospital doctor declared her healthy enough to return home.
So, on March 27, paramedics in hazmat suits delivered Ms. Van Peteghem, on a stretcher, to the door of Christalain.
Mr. Doyen greeted them wearing a surgical mask.
“Is this mask all you have?” the paramedics asked, Mr. Doyen recalled.
“Yes,” he said.
“Good luck,” they responded.
For the next hour, Christalain staff members watched as the paramedics decontaminated themselves and their ambulance. Asked later about the hospital’s policies, the chief executive, Prof. Marc Noppen, said infectious patients were not normally returned to nursing homes but that it may have happened in some cases.
No one can be certain if Ms. Van Peteghem’s return was the reason, but Covid-19 infections in the home increased. Residents began dying. Ms. Van Peteghem, who initially survived the virus, died last month.
The Belgian authorities were aware of such problems, according to internal documents. “Some patients have returned from the hospital infected,” a government emergency committee wrote on March 25. “Several hot spots have been caused this way.”
The committee recommended testing nursing-home residents and establishing locations to house Covid-19 patients who would otherwise be returned to homes.
But national and regional authorities could not agree on those recommendations, and the country remained a hodgepodge of policies.
For another two weeks, even as the government expanded its testing capability, health advisers resisted adding nursing homes to the national testing priority list. They worried that even the newfound capacity would be unable to meet the demand under the broadened criteria, according to documents and government officials.
“The federal government had tests. Hospitals had tests,” said Dr. Emmanuel André, a virologist who was tapped as a top government adviser and who advocated for broader federal testing. “But nursing homes? There were no tests allowed.”
As a stopgap measure, Philippe De Backer, a minister who had been tapped to expand testing, pushed out an initial batch of nursing-home tests in early April. But he and others wanted residents formally added to the testing priority list. Support for that change finally coalesced on April 8. Mr. De Backer dialed into a conference call of the government’s risk-management group — one of many committees that set policy in Belgium.
“You can stop debating,” he said. “We’re testing in care homes.”
When the first results were announced, one in five residents tested positive. By then, more than 2,000 residents had already died.
As the testing debate unfolded in late March and early April, hospitals quietly stopped taking infected patients from nursing homes.
The policy — officially it was just advice — took shape in a series of memos from Belgian geriatric specialists.
“Unnecessary transfers are a risk for ambulance workers and emergency rooms,” read an early memo, signed by the Belgian Society for Gerontology and Geriatrics and two major hospitals.
Extremely frail patients and the terminally ill should receive palliative care and not be hospitalized, the memo said. The document offered a complex flowchart for deciding when to hospitalize nursing-home residents.
The gerontology society says that its advice — drafted in case of an overwhelmed hospital system — was misunderstood. The society is not a government agency, doctors there note, and it never intended to deny hospital care for the elderly.
But that is what happened.
Do Not Admit
On the morning of April 9, Dr. André, the government adviser, was preparing for the daily news briefing when one question, submitted in advance by a journalist, caught him by surprise: Would nursing-home residents soon be allowed to go to the hospital?
“Why is this question coming?” Dr. André remembers thinking. “Yes, of course they can.”
But time and again, nursing-home residents with Covid-19 symptoms were denied hospitalization, even when referred by doctors who had assessed that they might recover.
“The decision not to accept residents in hospitals really shocked me,” said Michel Hanset, a doctor in Brussels who tried in vain to admit several nursing-home patients.
No data exists on how often this happened, but Médecins Sans Frontières says about 30 percent of the homes it worked in during its deployment reported this problem.
Government figures are also telling. During the first weeks of the crisis, nearly two thirds of nursing-home residents’ deaths occurred in hospitals. But as the crisis worsened, and the geriatric memos began circulating, that number plummeted.
At the peak of the outbreak, a mere 14 percent of gravely ill residents made it to hospitals. The rest died in their nursing homes, according to government data compiled by Belgian scientists and released to The New York Times.
It is impossible to know how many deaths were preventable. But hospitals always had space. Even at the peak of the pandemic, 1,100 of the nation’s 2,400 intensive care beds were free, according to Niel Hens, a government adviser and University of Antwerp professor.
“Paramedics had been instructed by their referral hospital not to take patients over a certain age, often 75 but sometimes as low as 65,” Médecins Sans Frontières said in a July report.
Some senior regional and national officials acknowledge this problem.
“I heard from staff in care homes that emergency doctors were arriving, taking residents and then they were sending them back to care homes, saying they could not keep them in the hospital,” Christie Morreale, the top health official in Wallonia, Belgium’s French-speaking region, said in an interview.
Ms. De Block, the national health minister, declined to be interviewed and did not respond to written questions. In interviews, senior hospital doctors defended their policies. They said that nursing-home staff sought hospital care for terminally ill patients who needed to be comforted into death, not dragged to the hospital.
If nursing-home residents were denied admission, they say, it was because a doctor determined that they were unlikely to survive.
“If you think medical treatment is of benefit for that patient, he or she will be hospitalized,” said Professor Noppen, the UZ Brussel executive. “It’s as simple as that.”
Nursing-home administrators are adamant that was not the case.
“At a certain point, there was an implicit age limit,” said Marijke Verboven of Orpea group, which owns 60 homes around Belgium.
Mr. Moreels, whose nursing home, Val des Roses, also had an intervention from a Médecins Sans Frontières team, agreed. “The ambulance wouldn’t take them,” he said. “There was no detailed consultation. They just said ‘Why did you even call us?’”
The Brussels ambulance service denied any policy of refusing to take nursing-home residents to the hospital. Yet even some doctors are skeptical.
“We learned that people from care homes believed it was not even worth calling an ambulance,” said Dr. Charlotte Martin, the chief epidemiologist at Saint-Pierre Hospital in central Brussels. “They should have been the first ones to get in the pipeline. And instead they were just forgotten.”
At the Christalain home, activities resumed this summer and life inched toward something resembling normal. But a shadow remains: 14 residents have been confirmed to have died of Covid-19. Another, devastated and confused from the quarantine, killed herself in April.
Mr. Pacchioli, whose mother died after being refused hospitalization, is haunted by a question. “Maybe it wasn’t too late,” he said. “If she had gone to the hospital, maybe she would have survived.”
The Médecins Sans Frontières teams concluded their nursing-home missions in Belgium in mid-June. Some members returned to developing countries. Others now work in another rich nation in crisis: the United States.
Today, Ms. De Block, Belgium’s national health minister, speaks about the nursing homes as if they were an unfortunate footnote in a story of a successful government response. She notes with pride that Belgium never ran out of hospital beds.
“We took measures at the right moment,” she said in an interview, adding, “We can be proud.”
Reporting was contributed by David Kirkpatrick and Selam Gebrekidan in London, Julia Echikson and Koba Ryckewaert in Brussels, and Christina Anderson in Stockholm.
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