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https://doi.org/10.1177/0733464820924131
Journal of Applied Gerontology
1 –3
© The Author(s) 2020
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DOI: 10.1177/0733464820924131
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Commentary
In a 2001 book review of Laurie Garrett’s “Betrayal of Trust:
The Collapse of Global Public Health,” Dr Amir Attaran, the
then Director of International Health Research at Harvard,
referred to the content as the “stuff of nightmares” (Attaran,
2001). In her book, Garrett warns of profound vulnerabilities
across the network of public health arrangements, medical
institutions, and political infrastructure that could lead to the
rapid spread of a future nefarious virus with devastating con-
sequences (Garrett, 2000). Now, some two decades later,
many of those forewarnings have come to pass as countries
around the world attempt to control the spread of the novel
coronavirus (COVID-19). In the devastating 3 months since
first reports of people presenting with symptoms in China to
the devastating events unraveling in places such as Bergamo
(Italy) and New York City (USA), the COVID-19 pandemic
has, as of April 6, 2020, spread to more than 200 countries,
infected more than 2.7 million people, and taken more than
187,000 lives (World Health Organization [WHO], 2020).
The complete landscape of COVID-19’s clinical presen-
tation is emerging, but not yet fully understood. Similar to
other pathogens within the coronavirus family, COVID-19
targets the respiratory system (Rothan & Byrareddy, 2020).
New evidence is emerging, to suggest that COVID-19 may
also affect the nervous and cardiac systems thereby obscur-
ing how to effectively manage the disease process (Guo
et al., 2020; Wu et al., 2020). The Centers for Disease Control
and Prevention (CDC, 2020) report that after a 2- to 14-day
incubation period, symptomatic infected persons generally
present with cough, fever, myalgia, and shortness of breath.
Once infected, a person can experience a range of disease
severity, from someone being fully asymptomatic through to
someone fighting for their lives in a high acuity setting on a
ventilator.
According to the WHO-Europe, 95% of COVID-19
deaths are among people older than 60 years, and further,
50% of all deaths are among people 80 years and older
(Lardieri, 2020; WHO Regional Office for Europe, 2020).
Using an Italian and Chinese sample, Onder and colleagues
(2020) reported an overall case fatality rate of 7.2%, with
fatality rates between 0.3% and 0.4% for the 30- to 49-year
group, between 1.0% and 3.5% for the 50- to 69-year group,
and between 12.8% and 20.2% for those aged 70 years and
above. While others have reported lower aggregated case
fatality rates (Mahase, 2020; Porcheddu et al., 2020; Singhal,
2020), they all consistently report a concerning trend toward
higher fatality rates among older age groups. The CDC report
on their website that “Older adults and people who have
severe underlying medical conditions like heart or lung dis-
ease or diabetes seem to be at higher risk for developing
more serious complications from COVID-19 illness” (CDC,
2020). Overall, it has become rather clear that older persons,
especially those who have underlying chronic health condi-
tions, are at greater risk of contracting and experiencing seri-
ous illness with COVID-19 (Zhou et al., 2020).
Not all older persons will contract COVID-19 thereby
creating, for the purposes of our argument and for simplicity,
two possible theoretical groups. First, a group of older per-
sons who will acquire the virus and will struggle through the
disease trajectory and second, a group who will not acquire
the disease, but who will spend the next number of months
under crushing isolation and under a great deal of stress and
uncertainty. While the trajectory for each group differs, each
could have rather monumental consequential outcomes, all
of which could largely be mediated with appropriate early
supportive interventions.
First, consider the group of older persons who will acquire
the disease. Based on global trends, they are very likely to
require resource-intensive medical interventions, once
infected. The challenge is that there may not be sufficient
924131JAGXXX10.1177/0733464820924131Journal of Applied GerontologyLandry et al.
article-commentary2020
Manuscript received: April 16, 2020; final revision received: April
16, 2020; accepted: April 16, 2020
1Duke University, Durham, NC, USA
2Western Norway University of Applied Sciences, Bergen, Norway
3University of Bergen, Norway
4Oslo Metropolitan University, Norway
Corresponding Author:
Michel D. Landry, Duke Global Health Institute, Duke University,
310 Trent Drive, Durham, NC 27710, USA.
Email: mike.landry@duke.edu
Betrayal of Trust? The Impact
of the COVID-19 Global Pandemic
on Older Persons
Michel D. Landry1,2, Graziella Van den Bergh2,3, Kari Margrete Hjelle2,
Djenana Jalovcic2, and Hanne Kristin Tuntland2,4
2 Journal of Applied Gerontology 00(0)
medical staffing or equipment supply to meet the surge of
demand. The high infection and mortality rates among older
persons, relative to younger populations, have ignited equity
debates surrounding decision-making and allocation of
scarce resources required for survival (Nakazawa et al.,
2020; Rosenbaum, 2020; White & Lo, 2020). For instance,
in overcrowded hospitals where enormous imbalances of
supply and demand exist, the burden of complex emergency
medical decision-making creates important moral, ethical,
and political dilemmas. Under those conditions, there are
pronounced risks for allocation of scare resources to be done
in discriminatory ways (Fink, 2020; HelpAge International,
2020). To standardize complex allocation decisions, and to
guard against explicit discrimination, White and Lo (2020)
established an explicit, accountable, and transparent alloca-
tion framework that can be used to allocate intensive care
beds and ventilators during the COVID-19 pandemic that
does not discriminate based on age. While we fully appreci-
ate that disaster and emergency pandemic medicine engen-
ders the need to reallocate scarce resources, we also believe
that even consideration of basing resource allocation deci-
sions on age would be socially and morally regressive.
Nevertheless, recent media reports of older people giving up
their ventilators, or speculations that older person should do
everything to save a younger person’s life, has fed into the
narrative that older persons have less value (Rodriguez,
2020; Wray, 2020).
The second group comprises older persons who will not
contract the disease, but who are now socially and physi-
cally isolated. The global population is now encouraged,
and in some countries legally and militarily forced, to
engage in self-isolation to reduce the spread of the virus
and to flatten the curve in the rate of new cases. Such pub-
lic health measures are designed and implemented to pro-
tect the entire population, but given their higher risk of
contracting COVID-19, older persons have been even
more strongly advised to isolate to reduce their exposure.
Paradoxically, even though these measures are meant to
protect, we contend that they may have unintended nega-
tive consequences on segments of older persons. For
instance, frail home-dwelling older persons who rely on
home-based care for survival are likely to receive fewer
home visits, which in turn will negatively influence their
health or functional level. Other older persons living fully
independently or living in supportive institutions are also
likely to experience reduced levels of activity, which can
exert important negative long-term consequences. Physical
movement must be a core activity in older persons` every-
day life to optimize independence and mental health
(Tuntland et al., 2019) and being confined under greater
isolation presents a high risk of functional decline from the
isolation (that paradoxically is meant to protect them).
Healthy aging-in-place is seen as enabling people to main-
tain independence, autonomy, and connection to social
support (Wiles et al., 2012). Although, in the times of the
COVID-19 pandemic, “unhealthy” aging-in-place seems
to be emerging and we are concerned that the long-term
outcomes could be devastating for older persons in this
group.
Overall, we highlight that the impact of emergency triage
decisions and robust public health preventive measures dur-
ing this pandemic may exert a disproportionate impact on
older persons. We signal that even in challenging times such
as these, dignity and rights of older people must, and can, be
preserved. To optimize physical and mental health of older
persons during these moments of extreme restrictions, we
argue that public health measures to control the pandemic
should be accompanied and balanced with supportive pro-
grams that will protect older persons from physical and
mental decline. To avoid “betrayal of trust” in the times of
pandemic, we must protect older people’s rights, on one
hand, by ensuring that the allocation of scarce life-saving
resources is solely based on clinical judgments and not
fueled by ageism, stereotypes, and biases, and on the other
hand, by providing safe, innovative, and accessible support-
ive services that will help older people maintain their physi-
cal and mental health.
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