"If we are to improve employment security in care provision and stop pathologizing old age, we need to rethink the concept of home"

 

Daniel López is one of the researchers at the UOC Internet Interdisciplinary Institute's CareNet research group, which explores the changes in the provision of support and care in a society in which technology is playing an increasingly prominent role. The group also approaches this issue from the perspective of crises, disasters and emergencies such as the COVID-19 pandemic. López has centred his research on old age and the role played by technological and social innovations in structuring the provision of care and defining old age itself. In this interview, he analyses the care challenges raised by the pandemic.

 

Daniel López is one of the researchers at the UOC Internet Interdisciplinary Institute's CareNet research group, which explores the changes in the provision of support and care in a society in which technology is playing an increasingly prominent role. The group also approaches this issue from the perspective of crises, disasters and emergencies such as the COVID-19 pandemic. López has centred his research on old age and the role played by technological and social innovations in structuring the provision of care and defining old age itself. In this interview, he analyses the care challenges raised by the pandemic.

With the pandemic, a number of structural problems affecting care homes that were already known (poor work conditions for care home workers, for example) were brought to the surface in the worst possible way. The late, inadequate response to the pandemic shows what place care homes had on the scale of priorities in public policies. Both elderly people's associations and academics and professionals working in geriatrics and gerontology had been saying for many years that we needed to move toward a different model. For example, the Catalan Society of Geriatrics and Gerontology is currently advocating an open debate on the long-term care model. Similar initiatives are emerging in civil society, such as the citizen platform "Volem llars per viure (We want homes to live in).

Care homes are still conceived as institutions, places that are disconnected from the public sphere and basically designed to maximize efficiency in the provision of care services. Although they are the place where many elderly people live, they are not thought of as homes where one would want to live. Consequently, people go there, or are taken there, when there are no other options, normally when resources and space at their homes are no longer sufficient and, in many cases, because relatives, friends or neighbours can no longer cope with the situation. The pandemic has been a stress test that has shown us all these shortcomings, and not just at the care homes.

It now seems urgent to change the model and, because of the pandemic, it seems that the political parties and civil society are starting to see it as a priority. I would say that it already was and it still is. But changing it now also entails some major risks.

We can easily make the mistake of believing that the care home problem is a COVID-19 problem. As if they were the same thing. Changing the model is not just a matter of making care homes safer. If we only do that, we are not addressing the structural problem. If we medicalize care homes, develop the hospital-based model and, in order to make the places more secure against COVID-19, give them more resources and improve coordination between social and health care, perhaps what we will be doing is further intensifying the medicalization and institutionalization of old age. In other words, we are worsening a significant part of the structural problems that were already there. Nobody wants to live their old age institutionalized in a bunker. That is why I think it is a mistake to put the focus solely on the care homes and develop the hospital model. We need another model.

The pandemic has shown us that we need to rethink the concept of home to build a care model that does not pathologize old age and perpetuate the insecurity of long-term care. Growing old in one's own home may mean many different things and so, we must explore new architectural and urban planning models. We must stop thinking acritically that growing old in one's own home is the best possible solution. The predominant concept of home generates problems in old age that we cannot ignore (violence, isolation). So we must guarantee the right to a home in old age, explore different and sustainable ways of growing old at home and, most particularly, combat the exploitation and job insecurity suffered by the people who provide care to people, either in their own homes or in a care home. It is important to deinstitutionalize dependency. The necessary resources must be made available so that the burden of caring for the elderly is not borne by the families and we must stop naturalizing the feminization of care work.

We need different housing and services models, but we must also challenge the family-centred model and the insecurity and feminization of care work. Obviously, we need places like the care homes, where people can benefit from continuous care and coordinated, professionally-delivered, interdisciplinary, intensive social and health care. But these places must also be places to live in, where people can feel at home. And also dignified, safe places for the people who work there. Making this change will require making profound changes at many levels.

Architecture, care models, training and professional culture. As has been found in other countries, care homes must be deinstitutionalized and this is not possible if we do not acknowledge that care in old age must be at the core of public policy. It should be a first-order public responsibility and a right that everyone is entitled to, just as health is today. It must stop being a private matter that families must deal with themselves, or cover by contracting private services. We have seen that this aggravates the exploitation suffered by the women who provide the care and, in emergency situations and catastrophes, it has devastating effects.

When we are shown the Nordic models for care homes, or caring at home, or the senior co-housing projects, we are usually shown things that can be seen: the architecture, the service model, the type of care, the ratios, etc. But the public policies that make this possible are fundamental and we rarely consider these. It's as if they weren't part of the models. But the policies are precisely the means by which society's priorities are turned into models.

These countries' policies have been very different from ours; first of all, because family and state are two very different things in both cases. The Nordic countries have a model based on individual rights and equality is a central value for their societies. Wherever they live and whoever they live with, people are entitled to receive the care they need, regardless of whether or not they have a family, or whether or not the family wants to be involved. In our case, in spite of all the socio-demographic changes, we still think that caring for the elderly is a private, family matter and … let's just say that our relationship with the authorities is not exactly grounded on trust.

The pandemic has worsened the isolation and unwanted loneliness experienced by many people, not just old people. However, the exceptional nature of the situation, the fact that the lockdown has been generalized and has affected everyone in one way or another, has also meant that these situations have become socially more visible. This has triggered a response. The social services, the community support networks and the networks of relatives and friends have been mobilized to mitigate the effects that isolation can have.

We have seen how video call systems have been rolled out from the care homes, how the support services for the elderly have been boosted, services such as Vincles and Radars, in the city of Barcelona, or Telecare have been essential in preventing the physical isolation of lockdown from becoming social isolation for many people. New services have been rolled out, and others that already existed have been transformed in response to the pandemic. This has been done in extremely difficult and very precarious conditions. If we really want to learn from what has happened and increase our readiness, we must assess what has been done and develop public policies that are capable of consolidating, strengthening and giving sustainability to the measures and support networks that have worked.

The public response came very late in the day for the care homes, even though we knew that they were places that are extremely vulnerable to COVID-19, because of the characteristics of the population who lives there. The clamour in support of the health professionals and the importance of saving lives was centred on the health system. The focus of attention were the ICUs and the health professionals. Obviously, we weren't looking at the care homes. That made us realize that the way that we have sectorialized care for the elderly was intensifying the pandemic's impact.

The division between health and social care has been one problem, particularly if we consider the chronic underfunding of the social and healthcare sectors. In most countries where they have had serious problems with the care homes, it has been seen that the virus simply exacerbated the effects of neoliberal policies, precisely because they have left the management of dependency in the hands of the private markets. Unlike what has happened with public health, the level of public protest about this has been much lower. If caring for the elderly – and not just the elderly – had the same status as health, no doubt our response would have been different. And I do not mean with this that we could have avoided losing so many lives. It would be stupid to say something like that in the current situation. But it is possible that we would not have thought just of "saving lives". I believe that these lives would have been lost differently. At least how we treat the people that we call elderly would have saved us other suffering, and also very significant and often invisible costs, because unfortunately they do not appear in the official figures.

The comparisons between countries are doing a lot of harm, especially because we will only know who has done it right or wrong "at the end". The criteria for establishing what is best or worst are not universally shared, and the data are not comparable, in most cases. We have seen this with the mortality rates. Every country has its own way of recording these things. It is essential to learn from what other countries are doing, but this type of ranking is not very helpful for doing things better.

First, I would say that the challenge of ageing is something that affects people of all ages and it is not necessarily a problem. It is only a problem if we view it from an economistic outlook, in which we associate old age with expense and ageing populations, with a tsunami that puts severe strains on the welfare system. This approach is ageist and neoliberal, and has devastating consequences. I prefer to focus the challenge from the acceptance of interdependence as something that is not exclusive to old age and putting policies at the service of an idea of "good life" that includes old age and, most particularly, what we call the fourth age or "high dependency".