‘Vaccination mandates for care staff will do more harm than good’

Covid-19 exposed the fact “that many countries’ long-term care systems around the world are broken,” David Grabowski, professor of healthcare policy at Harvard Medical School, tells Kathimerini. Professor Grabowski, who will speak at the Delphi Economic Forum, which takes place this year from May 10-15, expresses the hope that the lessons of the past year will lead to a greater emphasis on public health and disease prevention in the United States. He also speaks of his surprise at the inadequate crisis management in Europe and describes “long Covid” as an “important concern.”

How has Covid-19, with the tsunami of death it caused among the elderly, affected society’s attitude to aging? What core weaknesses in long-term senior care did it highlight in the US and elsewhere in the West?

The core weakness that Covid-19 exposed is that many countries’ long-term care systems around the world are broken. Similar to the US, many countries underinvest in home- and community-based care alternatives. As a result, many older adults end up receiving long-term care in large institutional settings. These settings proved to be terrible at containing a deadly virus. In many facilities, older adults share bedrooms and bathrooms. Staff move from room to room and often from facility to facility. The care is high-touch. This led to a “perfect storm” of sorts in which asymptomatic staff spread the virus across many residents and many facilities. Going forward, the US and other countries need to invest in more home-based care models and smaller nursing facilities. Research suggests smaller home models with private rooms and less staff traffic in and out of the building were better at protecting older adults from the virus.

Should hospitals and nursing homes make vaccination for Covid-19 mandatory?

In the US, most residents have voluntarily chosen to get vaccinated for Covid-19. Our best estimates suggest around 80-85% have been vaccinated. However, many staff have chosen not to get vaccinated, with rates around 50% and with tremendous variation by facility. As a result, many have called for mandatory vaccinations for staff. The US government has been reluctant to make it mandatory, especially because the vaccine was approved through an emergency use authorization. Although several assisted living chains have mandated the vaccine, most companies have not chosen this route. Everyone acknowledges that mandates will have the intended effect of increasing vaccination rates among staff. However, mandates are also likely to have the unintended effect of causing some staff to leave their positions rather than get vaccinated. Thus, I am worried that mandates will cause more harm than good by causing many staff to leave the workforce. Given severe staffing shortages and the challenge of recruiting new workers to these jobs, facilities can ill afford to lose more workers.

How concerned should be we about “long Covid”? How widespread is it, and how debilitating? Are you hopeful that vaccines can help on this front as well?

Long Covid is an important concern but we lack data right now on how widespread it is and how it is impacting individuals. This is an important area for future study, including how the vaccines might help with addressing this potential issue.

Will the pandemic leave a lasting positive legacy in the West in terms of health preparedness? Will it strengthen the realization that healthcare is a right and should not be dependent on employment or income?

I hope the pandemic will change US health and long-term care forever. The US system has always been about addressing illness rather than preventing illness. The pandemic showed that public health, in addition to medicine, is incredibly important. The key will be whether the US chooses to heed this lesson. Many policymakers are saying the right things, but I worry that as we move into a post-pandemic world, where we have lots of issues in need of attention, these lessons will be forgotten.

A fifth of global deaths, a quarter of all cases, but now also more than a quarter of all vaccinations – what peculiarities of the US – its administration, its healthcare structures, its libertarian streak – account for these numbers?

The US is terrible at preventing illness but very good at developing technologies and medicines to fight illness. As a result, this pandemic showed us the best and worst of the US healthcare system. The best was the development and deployment of the vaccine. The worst was the way in which the US failed to invest in measures to protect many frail older adults from the virus.

Europe, on the other hand, finds itself in the worst of all worlds right now: progressing too slowly on vaccinations, unable to impose lockdowns draconian enough to crush the virus, it is currently going through a brutal third wave. Are you surprised at this poor performance, given the supposed strength of European health and social support systems (at least compared to the US)?

I was surprised that many European countries didn’t fare better throughout the pandemic. I think it shows the challenges of containing a virus that spreads without symptoms. For example, even countries like the Netherlands that invest heavily in long-term care for older adults had high numbers of deaths in long-term care facilities. This was surprising. It says to me that if Covid is in the community around a long-term care facility, it is very challenging to keep it out, no matter how much money you spend on staff and other resources.