Despite numerous advantages in quality and accessibility of healthcare, developed nations have been hit particularly hard by the depradations of SARS-CoV-2. For all the benefits their citizens enjoy, it has become apparent that these nations’ ageing populations are uniquely susceptible to public health crises. With this trend set to continue, is it time to sound the alarm on the industrialised world’s looming demographic collapse?
When the scale of the COVID-19 pandemic first became apparent, governments and public health bodies scrambled to engage measures that protected hospitals from becoming overrun and entire healthcare systems from being overwhelmed. In this endeavour, most have been remarkably successful. With a few exceptions thus far, the initially catastrophic projections of mass graves, overflowing hospital wards lined with the sick, and whole nations crippled by infected workforces have largely not come to pass.
Whilst such an unmitigated disaster has been avoided in the hospitals, this has not been so in care homes. Across a range of different nations, economies and cultures, the impact of coronavirus when unleashed amongst the old has been grimly similar; a wave of mass death on a scale that even the most sophisticated and well developed care sectors have been wholly unequipped to manage.
Following a consistent decline in fertility rates accompanied by an increase in life expectancy, the population of industrialised nations, particularly those of Europe and Northeast Asia, are rapidly ageing. Despite all the advantages in the quality and availability of healthcare that citizens of such nations enjoy, the last few months has revealed the immense vulnerability of an ageing population to a public health crisis.
The effects of biological senescence on the human animal are manifold. Muscle atrophy causes physical weakness, misrepair of facial collagen fibres cause wrinkles, and neurodegeneration causes cognitive decline and dementia. But most important is the manner in which the passage of time dysregulates cell signalling pathways, leaving the body frail, sickly, and unable to mount an effective immune response. Diseases that may be minor inconveniences to the young are frequently life-threatening in old age. For all the astounding medical advances made in the past century, no therapeutic intervention has been developed to halt or even delay the process of ageing, and none are likely to be forthcoming. For the foreseeable future, old age, disease, and death remains the inevitable fate of all mankind regardless of wealth, status or nationality. This is an inescapable truth of which we have all been cruelly reminded in the past months, as a respiratory disease which is practically harmless to the young and healthy has claimed hundreds of thousands in the twilight of their years.
As more reliable statistics emerge, the magnitude of the disease’s toll on older generations is becoming apparent. In Italy, for example, 22% of the population are over the age of 65, among the highest proportions in the world. And as of the publication of this article, coronavirus deaths from this age cohort represent over 85% of the total. This pattern is very much repeated throughout Europe. In Sweden for example, a nation often hailed for its highly developed medical infrastructure and welfare state, more than 90% of the country’s dead have been over the age of 70. Whilst some nations with highly publicised demographic contractions such as Greece and Japan have thus far been able to avoid the worst of the pandemic, it is little wonder that those nations worst affected are also some of the oldest societies in the world.
The word “unprecedented” has been thrown around rather frequently in the past few months. A public health crisis on the scale of the COVID-19 pandemic is indeed unprecedented, at least in our lifetimes. Also unprecedented in all of human history is a society where over one fifth of the population are too old to work. Care homes, relatively new institutions that have now propagated across the industrialised world to cater for its ever-expanding elderly population, have been particularly hard hit. Though data-collection methods differ between countries and will likely be subject to change following the publishing of this article, it is estimated that deaths in care homes account for anywhere up to half of total COVID-19 mortality.
Chronically underpaid and undervalued, this job is certainly not for everyone; turnover in the British care sector stands at 30.7%, equivalent to around 390,000 leavers a year. To fill vacancies, governments of rich nations must turn to workers from overseas, typically working class women from poorer countries, who are willing to do the vital jobs their own citizens would snub their noses at. Again in the UK, it is estimated that 17% of care workers are migrants, and that this figure reaches 40% in the cosmopolitan centre of London.
Funding, maintaining, and staffing these sprawling and expanding systems that house and care for an ever growing portion of the population is already proving difficult. While, activists point out, the UK’s system is rather uniquely underfunded and understaffed for Western Europe, the particular vulnerability of care homes in all countries to infectious disease was made evident by coronavirus. Housing large numbers of the nation’s frailest and most vulnerable in close proximity, where all must be in personal contact with several different rotating carers – many of whom may be working a second job and have household members also working essential roles – has proven disastrous.
During the peak of the nation’s coronavirus outbreak, units of the Spanish military tasked with disinfection of nursing homes were met with scenes that bordered on apocalyptic. Reports described dead and dying residents discarded by staff either piled in the open or simply left to die in their beds. This wretched affair was unfortunately not an isolated incident. Similar stories of residents being abandoned to the virus by overworked and exhausted care staff have been reported in Canada and Italy.
Most nations in Europe, North America and East Asia appear now to have ridden out the worst of the first-peak of COVID-19. But if these unmitigated disasters do not convince us of the unsustainability of our current care model, then it is difficult to imagine what would. Once again using Italy as a benchmark for Europe’s ageing, 35% of the nation is projected to be over 65 by 2050. In turn, the total population of the country is expected to contract by approximately 10%, from 60 million today to 54 million, meaning that Italy will have a retirement-age population of 19 million by 2050 supported by a working-age population of approximately 29 million. Even if one ignores the political, societal, and economic impact of this kind of catastrophic depopulation – the kind of which is typically only seen during famine, plague, or war – the consequences for elderly care are disastrous on their own. If we assume that, as with Britain, 4% of those over 65 will require accommodation in nursing homes, this amounts to 760,000 total residents – 1.14% of the total population. Over one in every hundred citizens requiring round-the-clock care in purpose-built facilities in every city, town, and neighbourhood.
Where will such facilities be built? Who will staff them? Who will pay for it and how? For now, the obvious and immediate solution will be to throw more money at it. The natural consequence of this will be that, in many nations, the care sector will require increasingly expansive governmental departments and an ever growing portion of the national budget. But if populations continue to age and contract exponentially, for how long could that be sustained?
As the number of retirees grow and the size of the workforce correspondingly shrinks, the recruitment issues faced by many countries’ care sectors will only worsen. The natural option for many rich nations will be to plug the gap with immigrants. In many ageing nations that are averse to large-scale immigration, such as Japan, Poland, and Hungary, this will be a politically explosive decision. In other countries, the political costs might be fewer, but such a measure will likely have diminishing returns. An ageing population will result in vacancies opening in many areas of the job market, not just in the care sector, and most immigrants hardly made the decision to start a new life in a new country so that they can wash and feed its elderly. The difficulty in executing this kind of wholesale import of care workers was recently illustrated by the government of Quebec’s controversial attempts to attract immigrants and asylum seekers on the condition that they work as CHSLD (centre d’hébergement de soins de longue durée) orderlies.
Even if many richer nations are successful in pillaging the workforces of poorer countries to compensate for their labour shortages, the options remain far slimmer for the growing group of middle-income nations set to become old before they become rich. Moldova is by many measures the poorest state in Europe and is currently undergoing one of the worst demographic declines in the world, the severity of which is so great that the country’s politicians have begun to frame it in existential terms. The bitter irony of Moldova’s fate is that part of its emigration-induced worker shortage includes the thousands of women who have left to Italy to work as “badanti” – carers for the elderly. If Canada and the UK are struggling to fill their care homes with overseas workers, how can countries like Moldova, with meagre public funds and no higher wages or standard of living to entice foreigners away from their countries, possibly hope to maintain a well-functioning care system?
The short answer is they probably won’t. In poorer nations, the elderly are already some of the most marginalised members of society. And with the state completely incapable of meeting their growing needs, this situation will only get worse. Care responsibilities will likely fall on families and local communities. For some, this will be preferable. Many others, however, are likely to fall through the cracks. Each cold winter and hot summer will bring unacceptably high rates of mortality from largely preventable causes, and many of those with less stable community connections will find themselves dying alone, impoverished, and forgotten.
This seemingly dystopian future is not likely to spare richer nations. Already in Japan, officials speak of an epidemic of “kodokushi” – old people dying alone in their apartments and remaining undiscovered for weeks, months, occasionally years. Putting all these unfortunate souls in care homes may not be an option. If the care sectors of some of the richest, most advanced nations were so utterly swamped by a virus with a 1% mortality rate, the result will be truly catastrophic if a similar plague hits in 30 years, when the planet is significantly older and care homes even more overcrowded and understaffed. This grim possibility must give us pause to reconsider whether the current approach to elderly care is sustainable or even desirable.
But what alternatives exist? As with many challenges of the modern world, there are rather few historical precedents to guide us. Indeed, approaches to such a novel problem will require equally novel solutions, many of which are only just being considered. However, as with the looming crises presented by climate change, solutions will require serious and immediate research; the consequences of delaying these questions for another generation will likely lead us sleepwalking into disaster.
In the biomedical sector, there is increasing interest in the field of preventative medicine and treatment of age-related disorders. Particularly important among these are chronic conditions such as osteoporosis, arthritis and dementia that lead to gradual erosion of one’s physical and mental capacities, eventually reducing autonomy to the extent that a patient will require their basic needs met in a care facility. Indeed, in Britain it is estimated that dementia patients make up 40% of the entire care home population. It is hoped that better treatment of such conditions could allow for patients to retain their autonomy and dignity, whilst also reducing strain on the care sector. However, the challenges encountered in treating or even identifying the aetiologies of neurodegenerative disorders such as Alzheimer’s Disease shows the extreme difficulty in researching such age-related conditions, whose causes are presumed to be multimodal. It is likely to be several decades before real progress is made.
Other solutions have fewer practical difficulties but require a great deal of political will. Many countries with the most profound ageing problems, such as Japan, Hungary and Russia, have instituted pro-natalist policies that provide financial incentives for citizens to start families, with the stated aim of increasing fertility rates and slowing or even halting population decline. The results of these endeavours have been mixed but it may still be too early to gauge their true impact. Even if they are successful, such measures may not sit well with the more liberally-minded populations of the English-speaking world. At best, they may be seen as an unwanted state intrusion in the lives of private citizens. At worst, a paternalistic attempt at social engineering.
Another policy choice that may be more palatable to many is the encouragement of multi-generational living. This was how the old and infirm were historically cared for (and indeed still are in many parts of the world); with no state or private infrastructure to fall back on, care responsibilities fell on the younger members of the family and the local community. For many elderly people, the familiar sight of a friend or relative may be far preferable to the often rather impersonal services they may receive in a government or private care home staffed by professionals. However, multi-generational households have become exceedingly rare in the industrialised world, as the combination of social, cultural and economic factors has led to a far more atomised, urban existence. Reverting to this more communal manner of living would still require enormous social adjustment, and may be a step too far for many.
Some of these options may be unpalatable, and none are certain to even be implementable. But what is certain is that after COVID-19 has passed, the economic, social, and political pressures of an ageing society will only continue to multiply. Even without another pandemic, this will be the major political and biomedical question of our time. But unfortunately, COVID-19 is unlikely to be the last pandemic in human history. And like most plagues, the next one will also disproportionately kill the old and infirm. In the meantime, perhaps we can at least be grateful that this one spared the children.