This blog was written by Dr Peter Lloyd-Sherlock, Professor of Social Policy and International Development at UEA, as a response to an Editorial posted on The BMJ-– COVID-19: why we need a national health and social care service

Dear Editor

In high-income countries, concerns about large numbers of COVID-19 deaths in residential long-term facilities (LTFs) have been widely documented in the media and emerging academic literature [1]. It is likely that low and middle-income countries (LMICs) will eventually account for the majority of associated mortality, and, just as in high-income countries, deaths will be strongly concentrated among the oldest age groups [2].

The international literature and media have made virtually no reference to the specific risks posed to residents and staff based in similar facilities in LMICs. This reflects a general misconception that almost no older people in LMICs live in LTFS, reflecting strong social norms of intergenerational support and the wide availability of unpaid, largely female, family care [3].

Yet this is not the reality in many LMICs, especially in large urban centres. In Argentina, for example, the National Association of Long-Term Care Providers estimated that there were around 6,000 LTFs operating in the country in 2010 [4]. Many of these care homes operate informally, outside or on the fringes of legality, and subject to little if any regulation or quality assurance. Similar findings have been reported in other LMICs [5 and 6]. Responsibility is often divided between different local government departments (typically health and social development). There is growing evidence that conditions are often very poor and single bedrooms are a rare exception. These LTFs represent a very high-risk environment for COVID-19 infection.

Some national and regional agencies are seeking to develop guidance for COVID-19 management in LTFs [7]. The World Health Organisation has provided some useful technical guidance for LTFs [8], but this is not always appropriate to the needs of many facilities, even in high-income countries, due to resources and space constraints [9]. Regardless of guideline suitability, the limited capacity of official regulators will reduce scope to implement or enforce them. There is emerging evidence from the field of widespread misinformation and inappropriate responses in these settings. We have received reports of LTFs which are yet to develop infection control protocols and other facilities which are denying family members all contact with or updates about residents (few of whom have access to telephones or computers).

There is an urgent need to rapidly upgrade the capacity of government agencies responsible for regulating LTFs in LMICs and to strengthen coordination when responsibilities are split. Where many LTFs are run on an informal, illegal basis, there may be a strong case to offer these facilities guaranteed amnesties from prosecution in exchange for cooperation in responding to the pandemic. There are precedents with previous collaborations between public health entities and illegal brothels to improve control of HIV and other sexually transmitted infections [10]. Also, regulators should hold urgent meetings with local LTF managers and civil society organisations representing the interests of older people, to ensure that key stakeholders participate in the development of local strategies. Where feasible, civil society organisations should seek to rapidly map LTFs and monitor in their locales, since many may not be on official registers. There is some evidence that this can be effective when deployed in combination with social media and online platforms [11].

More generally, across LMICS there is a need to overcome widespread denial about growing numbers of LTFs and the low quality of care they sometimes provide. The current crisis may represent an opportunity to increase the profile of this issue among policy-makers and to develop effective regulation.

Co-authors: Joao Bastos Freire Neto, Adelina Comas-Herrera and Nelida Redondo.

REFERENCES

1. Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. ePub: 27 March 2020. DOI:http://dx.doi.org.uea.idm.oclc.org/10.15585/mmwr.mm6913e1externalicon [accessed 8.4.20].
2. Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M Bearing the brunt of COVID-19: older people in low and middle-income countries. BMJ. 2020 Mar 13;368:m1052.
3. UN Women Long-term care for older people: A new global gender priority.https://www.unwomen.org/en/digital-library/publications/2017/12/long-ter…[accessed 8.4.20]
4. Lloyd-Sherlock P, Penhale B, Redondo N. The Admission of Older People Into Residential Care Homes in Argentina: Coercion and Human Rights Abuse. Gerontologist. 2019 Jul 16;59(4):610-618.
5. P.Lloyd-Sherlock, S.Sasat, A.Sanee, Y.Miyoshi, S. Lee The rapid expansion of residential long-term care services in Bangkok: a challenge for regulation. School of International Development, University of East Anglia, Working Paper 55.https://www.uea.ac.uk/documents/6347571/6504346/WP-55/2a384864-5397-53e6…[accessed 8.4.20].
6. P.Lloyd-Sherlock Long-term care and human rights violation in South Africa: the tip of an iceberg? BMJ 2016;354:i5126.
7. Economic Commission for Latin America and the Caribbean COVID-19 Recomendaciones generales para la atención a personas mayores desde una perspectiva de derechos humanoshttps://www.cepal.org/es/publicaciones/45316-covid-19-recomendaciones-ge…[accessed 8.4.20].
8. World Health Organisation IPC guidance for long-term care facilities in the context of COVID-19.https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IP…[accessed 8.4.20].
9. https://www.theguardian.com/world/2020/apr/08/canadian-nursing-home-reel…[accessed 8.4.20].
10. Ghose T, Swendeman DT, George SM. The role of brothels in reducing HIV risk in Sonagachi, India. Qual Health Res. 2011 May;21(5):587-600.
11. La Red Mayor http://www.redmayorlaplata.com/ [accessed 8.4.20].