All of Us

Getting the Narratives Right About Nursing Homes and Residential Housing

by MakeUsWell

The COVID Tracking Project at The Atlantic contains this summary statement:

Less than 1% of America’s population lives in long term care facilities, but, as of March 4, 2021, this tiny fraction of the country accounts for 34% of US COVID 19 deaths.

The authors of the COVID Tracking Project actually note that the correct percentage is higher:

CTP’s aggregated cumulative data for these states under-reports actual cumulative totals. This information can be found in our Aggregate Dataset. States vary in their reported cumulative data start date. Not all states and territories report long-term-care data.

Public media have offered three narratives explaining why long-term care facilities have experienced so many deaths:

  • Narrative 1:  Older people who live in these facilities are more at risk of dying from the COVID-19 virus because they usually have one or more underlying health conditions.
  • Narrative 2: More people of color reside in long term care facilities. They are more at risk of dying because of poor health and poor healthcare access.
  • Narrative 3:  The majority of long-term care facilities are for-profit and have poorer staff coverage and healthcare.  As a result, more residents die.  

A fourth narrative is included with all of the first three:  minimum wage nursing home staff members bring the virus into the nursing homes and cause more residents to die.

These narratives are partially true, but incomplete. To understand why they were incomplete, we had to dig more deeply to find data than was easily available in government or mass media sources.

Connecticut hired Mathematica, which presented 45 recommendations relative to improving nursing home management to the Governor and the General Assembly at the end of September, 2020.  This report was better than most in identifying some potential root causes, such as poor leadership and staff focus on infection control.  

But too many variances were not readily explained by these narratives. Two facts stood out as we looked at long-term care facility data reporting:

  • Death rates varied from 0 in some long-term care facilities to an excess of 50% in a small number of other long-term care facilities. There was little effort to understand what caused the outliers in either direction.
  • Factors other than those identified above may have been major root causes, but the best research to support those factors was done outside the US.

Three alternative narratives may be more persuasive and scientifically valid:

  • When nursing home facilities are overcrowded (averaging more than two residents per room), more residents die (data from a province of Ontario study);
  • When ventilation, filtration, and disinfection of air is substandard, more residents and staff will die. Because the virus will infect more people with higher viral loads if it has no chance of leaving an indoor space.  
  • If basic infection control is missing (e.g. mask-wearing, segregation of infected patients, regular testing of staff, and tight control of visitors), more residents and staff will die.

These narratives are more likely to explain why so many people died in nursing homes.  They also explain why so many people living in severely overcrowded, poorly ventilated housing who lack a good understanding of infection control suffered a horrific number of non-nursing home deaths.  

One study estimates that, compared with a baseline percentage of poor-quality housing, every 5% increase in poor housing quality results in a 42% increase in COVID-19 deaths.

Less overcrowded, well-ventilated, well-filtered and properly infection-controlled spaces reduce death rates. This reduction is across every other airborne infectious disease.  And in nursing homes and residential housing.

Getting the narratives right is a matter of life and death.