Managing nursing homes in a pandemic context: a three-ringed circus

During the first weeks of the COVID-19 pandemic, a regional health minister of a European country, responsible for purchasing masks, gloves, and other personal protection equipment (PPE) for his region, asked his fellow regional health ministers on a phone chatting app how they were calculating their purchase needs. All but one replied with formulas that only took into consideration the expected needs for the personnel of hospitals and healthcare centres. The odd one, who was in charge of both healthcare and social services in his region, asked the other regional ministers whether they considered that non-health facilities such as prisons, garrisons, or nursing homes could also need PPE. Surprised by this concern, which had not crossed his mind up to that moment, the regional minister who asked the initial question replied: ‘Please, elaborate on this idea’. This telling anecdote shows how the care homes sector was completely out of the mental framework of the authorities having to deal with the initial stages of the pandemic. This lack of focus on this sector had very significant consequences for the way in which the disease expanded among the residents of this type of institution, and on the measures adopted to respond to this public health emergency in the early stages of expansion of the pandemic (del Pino et al, 2020).

Introduction

In Austria, the devastating impact of the pandemic in neighbouring Italy, including an overcrowded health system and a high death toll, was covered broadly in the media and resulted in significant respect – if not fear – of the potential consequences of this novel disease already in February 2020. The Austrian government reacted quickly and imposed rather strict measures (Hale et al, 2021) to contain infections and to avoid catastrophic situations in hospitals, as observed in reports from the neighbouring country. With effect from week 12/2020, schools had to jump into ‘remote teaching’. Due to the complete lack of experience and preparation for this teaching mode, most pupils had several weeks’ worth of lost education. Apart from those dealing with essential goods like grocery shops and pharmacies, all shops went into lockdown. Employees were urged to work from home wherever possible. A strict curfew was imposed with a limited list of exceptions: necessary shopping, employment, help for persons in need of support, and outdoor activities like walking, running, and biking for the sake of health and sanity, given a safe distance to other people was kept (COVID-19-Maßnahmengesetz and related ordinances).1 Some measures were criticised as exceeding reasonable limits, like the closure of parks and children's playgrounds, because these measures might lead to a concentration of people in accessible areas. Some regulations were later declared as not justified by the Constitutional Court. A generous public support program for short-time work was introduced to facilitate compliance with the imposed measures and to stabilise the economy (§13 (1) Arbeitsmarktpolitik-Finanzierungsgesetz).

Introduction

The COVID-19 pandemic threw into stark profile the multiple structural weaknesses in English adult residential care, particularly compared with health services. These weaknesses include: the chronic underfunding of care services; the prioritisation of health in national policy priorities, governance, and leadership; fragmented relationships between national and local government institutions and actors; fragmented relationships between acute health and long-term care sectors, nationally and locally; the complex relationships between local government and local private residential care home quasi-markets; and chronic shortages of paid care workers. All these weaknesses are well known, so the publicity they received during the pandemic was little surprise. However, since the initial crisis of early 2020, few steps have been taken to address them. From April 2022, an increase in payroll taxes will generate more funding that is, in due course, intended to be ring-fenced for adult care services; and there are plans to improve local joint strategic planning and service commissioning between National Health Service (NHS) and local authorities. Most other institutional and governance weaknesses laid bare by the pandemic remain unaddressed.

This chapter focuses on England (containing 84 per cent of the United Kingdom population). Within the UK, responsibilities for health and care services are devolved to the English, Scottish, Welsh, and Northern Ireland governments. There is increasing divergence between countries in the structures, funding, and governance of their services; differences were also apparent in how the four countries responded to COVID-19.

Introduction

Italy was the first western country to be strongly hit by the COVID-19 outbreak. The first relevant clusters of infection were officially registered in two northern Italian regions (Codogno in Lombardy, and Vo’ in Veneto) on 21 February 2020. At that time, scientific information about COVID-19 and its potential dangers was still very scarce. The WHO did not proclaim COVID-19 as a ‘high global risk’ until 28 February 2020: on that same day, Italy already had 888 officially infected persons, 345 hospitalised COVID-19 patients, 105 patients in intensive therapy units (ICUs), and 21 deaths (open data from Protezione Civile).

Considering the total number of COVID-19 infections during the first phase of the pandemic, the cases counted at the end of May 2020 were 232,639. However, the peak was reached in March 2020, with 113,351, while in the following months, the trend decreased, reaching ‘only’ 22,893 cases in May 2020 (ISTAT -ISS, 2020).

According to available data, more than 70 per cent of positive cases reported between February and May 2020 were concentrated in a limited number of Northern Italian provinces in which the circulation of the infection was exceptionally high (that is, COVID-19 infection higher than 450 cases per 1000 residents) (ISTAT -ISS, 2020).

Introduction

Throughout the COVID-19 pandemic, the general aim in Finland was to protect older people and other at-risk groups. In the first phase of the pandemic (in the spring of 2020), multiple measures were adopted to protect older people and prevent the spreading of the virus in the social welfare units. The measures were adopted rapidly. In general, Finland coped relatively well with COVID-19. Nevertheless, the disease was fatal to older people, especially in the social welfare units. Older people living in care homes suffered in different ways. They were the most likely to die of COVID-19. For that reason and beyond, their rights were restricted during the pandemic in ways violating their fundamental rights.

Finland already had relatively new legislation governing emergencies when the COVID-19 pandemic started. Even though it turned out that the laws needed some alterations during the pandemic, the legislation gave the authorities the power and tools to act from the start. There was also both national and local contingency planning – which turned out to be inadequate and not sufficient, but did provide some preparedness. Nationwide, the number of cases and the number of hospitalised COVID-19 patients were moderate throughout the first phase of the pandemic. The first COVID-19 case was confirmed in late January 2020. By mid-March, the number of cases was 150 in total. The Finnish government announced a state of emergency, introduced the Emergency Powers Act on 16 March and ordered several measures to prevent the spread of the virus.

Introduction

This chapter provides a discussion on how European governments responded to the challenges posed by the Coronavirus (COVID-19) crisis in nursing homes. Particularly, it focuses on the integration of health and social service sectors and the coordination of different intergovernmental levels in the system for the care of institutionalised elderly individuals.

From the beginning of 2020, the coronavirus pandemic represented a highly intricate policy issue for European nursing homes, due not only to the characteristics of the affected population, but to the preexisting circumstances of these homes, and the nature of this multifaceted crisis. Additionally, governments had to take into account the intrinsic complexity of the relationship between the diverse actors involved in the long-term care (LTC) of the elderly, further exacerbated by the stressful context of the initial phase of the pandemic. Governments were faced with what we have called an ‘intersectoral intergovernmental complex problem’ (CIIP) (Paquet & Schertzer, 2020).

It is a reasonable assumption that governments which are required to address the management of a CIIP that cuts across two or more policy areas and two or more territorial jurisdictions will adopt an integrated policy approach, that is to say, a ‘set of formal and informal rules, norms, procedures, as well as values, beliefs, knowledge and skills, enabling the reconciliation of composite policy goals, harmonisation of multiple policy instruments and coordination of relevant policy actors’ (Domorenok et al, 2021a). However, our analysis of the initial responses to the challenges posed by the COVID-19 pandemic in nursing homes in 15 European governments during the first months of the crisis indicates that this assumption may have been overoptimistic.

Introduction

This chapter is about the COVID-19 pandemic in long term care residences (LTCR) in Portugal from 2 March 2020, to 15 July 2020. It was a dramatic period in which Portuguese society faced a threat unprecedented in the memory of people and institutions, about which little or nothing was known.

One of the most disconcerting facts that occurred was how the pandemic spread to the elderly and, in particular, those who were institutionalised in LTCR. However, this being the focus, we will only deviate from the topic and the fixed period when there is a need to frame them, namely regarding the pandemic's evolution and the LTCR network's evolution.

Although the period under analysis in this chapter is the four and a half months between 2 March 2020, when the first case of infection was detected, and 15 July 2020, when the first cycle of the pandemic ended, it is worth looking at its evolution from a broader perspective. This perspective reveals a much higher incidence of the disease after autumn 2020 than until then, as shown in Figure 13.1. The daily new cases recorded by the Directorate-General for Health were 53 per day at the beginning of March 2020, increasing to around 350 per day by July of the same year and coming close to 750 cases per day in early October 2020.

At that time, a wave of large proportions emerged, reaching a peak of almost 7,000 cases per day in mid-November and 15,000 per day in late January 2021. There are two crucial phenomena to register: first, the relationship between policies, population behaviour, and how people perceive the evolution of SARS-COV2 infections.

Introduction

This chapter examines the rapid rise of ‘digital humanitarianism’ in international development, specifically the expanding role of various digital platforms as a means for everyday citizens to interact with various humanitarian causes. The chapter analyses efforts made by evolving digital models towards creating greater space for horizontality in typically top-down aid structures. The concept of digital humanitarianism refers to the suite of digital technologies that allows swathes of individual people to contribute towards humanitarian action (Burns, 2019). While digital humanitarianism can take many forms – for example remote volunteering, coalition building or more recently as forms of virtual mutual aid – crowdfunding platforms and social media-based humanitarian campaigning have become increasingly prominent since 2010, particularly in the years before and certainly during the COVID-19 pandemic. These latter models feature heavily here in Chapter 7, as they form a core example of how virtual platforms aim to create neutrality and egalitarianism among users, whether they be digital humanitarians or those seeking support.

Crowdfunding platforms are a particularly interesting model of digital humanitarianism, as they often combine several aspects of the phenomenon including digital fundraising and virtual campaigning via social media outlets. Crowdfunding platforms specifically for international development projects – such as GlobalGiving and Kiva – provide an opportunity for individual donors, or ‘microphilanthropists’, to immerse themselves in the humanitarian process, creating ‘feelingful ties’ (Moodie, 2013) and social bonds between donors and recipients through digital connectivity.

Several years ago, after singing and dancing, I sat listening to a Women Protection Team (WPT) in the far north of South Sudan. They told me how a local rebel army had been raping women and abducting boys and forcing them to become child soldiers. The women had met with another WPT from a nearby town and heard that those women were experiencing the same problems. Jointly, they decided that they would walk to the rebel camp and confront the commander. A few days later, a small group of women started walking from the main road knowing that a large group would attract attention. En route, small groups joined them as they trekked through the bush. Susan, one of the unarmed civilian protectors who accompanied the group, said, ‘We footed for four hours.’ When they arrived at the gate of the camp, they told the guard that they wanted to talk with the commander. When the guards told them that was not possible, the women, by then numbering over 100, said they would wait.

Finally, they were allowed to meet with the commander. His first response was that he had never met with a group like that before, which no doubt was true.

The women said, ‘We are tired. We are tired of our children being abducted. We are tired of being raped. We are tired of the violence. And we want it to stop.’

Introduction

This chapter examines the evolving dynamics of South– South cooperation (SSC), development and humanitarianism, offering a critical exploration of their promises, complexities and contradictions. Framed within the broader discourse of global development, the chapter examines how South– South initiatives have emerged as a distinctive approach, often positioned as an alternative to the traditional, North– South development paradigm. By focusing on the intersections of cooperation and humanitarianism, it distinguishes between these two domains of analysis while highlighting their interconnections in practice. SSC encompasses state-led and multilateral initiatives among countries in the Global South, rooted in the premise that shared historical experiences – often marked by colonialism and postcolonial struggles – equip these nations with unique perspectives and capacities to support one another. This solidarity-driven framework operates on the assumption that countries of the Global South are better placed than their Global North counterparts to foster equitable partnerships and address development challenges. We critically interrogate whether the ideals of solidarity and mutual benefit are fully realized in practice or if new forms of inequality and dependency are emerging within these partnerships.

To illuminate these dynamics, the chapter draws on case studies situated at the intersection of Latin America and sub-Saharan Africa, focusing on the experiences of Brazil, Cuba and Mozambique. These examples include Cuba's renowned medical training programmes, which have established an enduring legacy of healthcare diplomacy, and Brazil's agricultural development projects in Mozambique, which reflect its ambitions as a rising power in the Global South.

The use of violence is about exercising power through force and fear, and nonviolence is a cooperative power. Understanding and integrating power into protection research, as more than the cause of the threat, is necessary to understand how unarmed civilian protect (UCP) is an approach that reduces and prevents violence. UCP is based on nonviolence, which has its own understanding of power.

Debates in protection should include thinking about power. At the start of this book, evidence was introduced that showed there is a huge need for protection because levels of violence against civilians are so high, and behind this violence is the normalization of violence towards civilians, which emerges from the dominance of militarism and the belief that using violence works.

Power is sometimes thought of as a fixed or zero-sum game: for example, states sometimes behave as if a fixed amount of power (Eyben, 2009) can be lost by one and gained by another. In reality, the amount of power, and who has it, is fluid and dependent on the cooperative or coercive power (Powercube, 2011) of a large number of different stakeholders and influences.

This chapter brings together all the different ideas from the other chapters to look at how thinking about power informs many of the debates in protection. Power itself is contested through the many ways we think about it, and different forms of power challenge the military threat approach, which is responsible for the protection threats that we are trying to prevent.

Some components of power have already been discussed in this book, including the myths of protection, cycles of violence, nonviolence and oppression.

This book has sought to document and implement parallel shifts in how we conceptualize and practise aid. Central to this effort has been a re-examination of development and humanitarianism. As discussed in the Introduction, Western-liberal, institutionalized forms of aid – largely shaped and directed by the Global North – have long dominated teaching, literature and policy making in this field. However, drawing on substantial new empirical evidence, including our own research and that of others, we argue for a fundamental shift in focus to recognize the multitude of alternative forms of aid. Specifically, we propose that these can be characterized as horizontal in contrast to the prevailing vertical forms, which are defined by power imbalances and hierarchical structures of knowledge and authority. Far from being novel or emergent, these horizontal forms often predate the institutionalized Western-liberal approaches. Their recent resurgence, including in contexts such as the COVID-19 pandemic, underscores their enduring relevance and adaptability. Indeed, we suggest that institutionalized aid may represent a brief episode within the much longer history of how humans have historically supported one another.

We have thus examined the critical impasse in teaching and practising development, particularly in light of the mounting critique of dominant paradigms. This critique has grown increasingly forceful, spurred by the movement to decolonize development and the enduring analysis of humanitarianism as a mechanism of governmentality and control. Key critiques revolve around race, class and inequalities in multifaceted forms (Mitchell and Pallister-Wilkins, 2023; Roth et al, 2024).

Building on the discussion in previous chapters of the transformative potential of unarmed civilian protection (UCP), this chapter explores our relationship with violence and power.

The way we think about violence is key to thinking about why protection can play a transformative role in addressing and removing the way threats of violence are sustained and accepted in politics. One of the key implications of UCP is that it demonstrates where the military is not necessary and where violence doesn't work. An essential component of the way in which systemic transformational change is envisioned in the deep commons (Deep Commons, nd) is cooperation to challenge the disassociation caused by militarism. For transformation to work, there need to be viable alternatives to militarism, and UCP can play an important role in creating these.

Different ways of thinking about violence

We talk about violence as if it is well defined and understood, but there are different ways that we define violence that are relevant to the bigger picture of protection. First, we need to separate violence, conflict and power, which are sometimes used interchangeably – power and conflict are normal, and violence is not. Conflict is a normal part of being human and valued when it is used peacefully to drive innovation. Hannah Arendt (1970) explained how violence and power are separate. Power comes in many forms. Some people use violence in trying to maintain or expand a fixed power base (see next chapter for more on power), but power is also fluid and based on collaboration.

Introduction

As the previous chapter illustrated, one form of transnational resource distribution is through members of diasporic groups. A key characteristic of diaspora support revolves around a particular set of affinities and commonalities, such as belonging to the same ethnicity, nationality or – in the case of more specifically directed support – kinship ties which structure remittances. What, though, can be said about transnational resource flows that are not based on pre-existing social relations, or kinship ties as conventionally understood? Chapter 6 explores transnational citizen aid, also described as grassroots international non-governmental organizations (INGOs) (Schnable, 2021), private aid initiatives (Kinsbergen, 2010) and vernacular humanitarianism (Brković, 2017). These are transnational initiatives often operating across national or regional borders, extending not only between residents in countries from the Global North to the South but also in North– North or South– South forms as well. These initiatives are horizontal – in the sense that they offer peer-to-peer (P2P) support, often at a grassroots level – and personal relationships are a central part of their inception and operation. Citizen aid initiatives most commonly precede, and often avoid, formal registration as NGOs, so in many cases they may even be considered informal forms of horizontal support. Many of them do not necessarily take the form of a registered organization but consist of mid-to long-term resource flows between individuals and communities.

From makeshift refugee camps in Europe to a multitude of micro projects across the world, the landscape of development is increasingly populated by such privately funded, small-scale aid activities.