Before the pandemic, our system of elder care was like dry kindling awaiting a spark


“How am I going to take care of my mom after dad is gone?” has always been a vexing question. The short answer is that either you or another family member will do it, or someone will be paid to do so.

For most of us, low-wage workers—almost all women, many immigrants, most of them black or brown —are the linchpin of how this question is answered daily. That’s true whether you hire an individual, hire a home health agency or move mom to assisted living or a nursing home.

COVID-19 drifted into the American consciousness in late February via reports of widespread infection and numerous deaths among elderly nursing home residents. The pandemic continues apace among the elderly, especially in facilities where they live in close proximity. Yet both the fundamental role of low-wage workers in caring for the elderly and their role in the pandemic remain unclear to most.

Donald H. Taylor Jr. is professor in the Sanford School of Public Policy, a founding faculty member of the Margolis Center for Health Policy and director of the Social Science Research Institute at Duke University. [Courtesy of Duke University]

Unless you or another relative cares for your mom, low-wage workers will literally touch her every day. Regardless of where she lives, they will help with dressing, bathing, eating, moving about and going to the toilet.

Nursing assistants and other health workers have helped my mom immensely since the death of my stepdad 13 months ago. My personal experience with these women has helped me understand a reality that I only knew as a researcher before — that the line between my mom declining and thriving as best she can is fine and fragile.

That line runs directly through the women who show up to care for my mom daily, typically as they juggle more than one job, or work nights while going to school during the day. The reliance on workers who themselves are vulnerable has long been the linchpin of how we care for our nation’s elderly. This precarious situation now presents a risk to public health in the midst of a novel infectious disease.

These workers are a central part of the COVID-19 story, and will remain so until a safe, effective and widely available vaccine or curative treatment is identified. Such workers are at risk due to occupational exposure to the virus that causes COVID-19. They also pose a transmission risk as they move back and forth between the community and elderly care settings, potentially carrying the virus with them.

This transmission chain may help explain why new cases have only plateaued in the United States, and have not declined appreciably even with extreme social distancing. And this chain of transmission is likely how a second wave of COVID-19 cases will be touched off in the fall and winter.

It is a national scandal that we cannot test all residents of nursing homes and other congregant living facilities for the elderly, and the workers who help them live. Universal and repetitive testing for residents and workers is an urgent public health priority.

Things are bad now for the elderly. They will almost certainly get worse next winter as illnesses and hospitalizations increase. Increased cases will necessitate greater need for short-stay nursing home rehabilitation, which poses a perpetual source of infection spread as residents come and go.

Two things are required to navigate the COVID-19 pandemic while providing the care that elderly persons need. First, we need a testing-based surveillance system that continually tests asymptomatic workers and residents until a safe and effective vaccine is developed. Second, we must keep low-wage workers and their patients safe by providing them with the needed protective equipment, and paid time off if they are sick. Without both elements, congregate facilities for the elderly will continue to drive the pandemic’s spread.

Before the COVID-19 pandemic, our system of caring for the elderly was like dry kindling waiting for a spark. Low-wage workers are not to be blamed for the concentration of coronavirus cases and deaths in nursing homes. Instead, they need to be appreciated and protected. Doing so will protect us all.

Donald H. Taylor Jr. is professor in the Sanford School of Public Policy, a founding faculty member of the Margolis Center for Health Policy and director of the Social Science Research Institute at Duke University. His own mother lives in assisted care, and he is writing a book about caring for your parents in the age of COVID-19.

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