How Americans Learned to Accept That “the Old” Would Die

In American Eldercide, author-activist Margaret Morganroth Gullette writes about how ageism—often intersecting with ableism, racism, and classism—led to US nursing home residents suffering a disproportionate number of deaths during the COVID-19 pandemic, numbering in the hundreds of thousands. In the section excerpted here, taken from the book’s third chapter, Gullette outlines how understaffing and ageism led to malign neglect for many of the nation’s then 1.4 million nursing home residents, with tragic consequences.

This excerpt is reprinted with permission from American Eldercide: How It Happened, How to Prevent It by Margaret Morganroth Gullette, published by the University of Chicago Press. © 2024 by Margaret Morganroth Gullette. All rights reserved.

The proximate cause of misery and harm was understaffing. Anguished family members, overworked aides, and indignant reformers had long suspected that many owners achieved profits by keeping staffing lean, a practice that inevitably overworks the remaining employees and leads to mistreatment of the captive audience.

Understaffing leads to neglected turning; poor skin care leads to pressure ulcers, grinding pain, sepsis, even death. Delays in responding to calls lead to falls and broken bones as people with limited mobility try to help themselves. Understaffing is correlated with more use of antipsychotics or (illegal) restraints. The practice was widespread, but Black or Latinx residents were likelier to suffer. Understaffing also leads to infections, a main source of misery, pain, and death long before COVID. CMS [Centers for Medicare & Medicaid Services] needed to mandate, not merely “urge,” higher standards.

These are ways that public emotions get constructed, almost invisibly.

The walls of protection that should have kept COVID outside, had been made porous—by governors who ordered hospitals to send patients with the virus to the ill-prepared nursing facilities, and by skin-flint operators, whose overworked aides had to pass in and out to similar second jobs, in risky contact with other residents. Staff attention was fragmented by heightened workloads and by anxiety about themselves and people they cared for.

In May 2020, the General Accounting Office confirmed the worst suspicions by reporting that understaffing had been a chronic issue prior to COVID and that its gravity had been neglected by CMS. In the pandemic the damages became only graver and apparently more widespread. An important symptom might be missed as just another appearance of aged frailty. A hacking cough might not get noticed by a tired aide in time. Isolated and fearful, some people who had been okay lost abilities to wash, dress, or control excretions. People who needed help eating were left alone long enough to die of dehydration. News stories recounted the conditions of those who had been neglected: their open sores, nasty sheets, cries for help, helplessness.

The walls of protection that should have kept COVID outside, had been made porous.

Such graphic accounts of abuse left the impression that the residents were merely bodies, weak, pitiable, physically disgusting. Confusing the inhabitants with their locales, a crude existing problem, became far more likely. These conditions and mortality data heightened the already repugnant image of “homes” as deadly warehouses. In April 2020, a former lieutenant governor of New York State was quoted in the New York Times referring to nursing facilities as “death pits.” Squalor became attached to the dying inhabitants as a group. The result was, I fear, a perverse appeal to a squeamish side that many of us possess. Lacking fuller context, this side is third cousin to bullying. It is first cousin to aversion. It is the bad brother of indifference. These are ways that public emotions get constructed, almost invisibly.

It is apt to contrast the residents with another group noted early on as vulnerable: medical personnel working extra shifts. They too were endangered, but their deaths were not described as squalid or pitiable; their bodies were not portrayed as helpless. They were properly regretted. “Our Heroes,” read appreciative signs that popped up everywhere. (That made the forgotten workers in nursing homes say, “Heroes work here too.”) The group of “the Old” was obviously unheroic, inessential, useless, frail.

Frailty has a “rather vague definition” medically: even after age eighty it affects a minority. But in some ugly part of the social imaginary, it meant just waiting to die, moribund. In April 2020, Ron DeSantis, the governor of a state populated by many older adults, thought fit to say out loud what others merely thought: “Florida is ground zero for the nursing home; I mean we’re God’s waiting room.”

In Simone Weil’s remarkable essay on the Iliad, the French philosopher of domination and subordination analyzed how power works between unequals. It “rests principally upon that marvelous indifference that the strong feel toward the weak, an indifference so contagious that it infects the very people who are the objects of it.” What is “marvelous,” perhaps, is that some of the stronger don’t even see these “objects.” The mass of residents dying was just a big number changing so fast that no one could remember it.