Elder Abuse

Print Friendly, PDF & Email

By Andrew Cockburn, Harper’s Magazine

Illustrations by Najeebah Al-Ghadban. Source photographs © Getty Images, iStock, Jean Mohr/World Health Organization, and Alamy

At the beginning of this year, Canterbury Rehabilitation and Healthcare Center, a nursing home in Richmond, Virginia, housed 160 elderly residents, roughly half of whom were African-American. Most of them were there courtesy of Medicaid, the government program that finances health care for those with little or no money. By mid-May, 80 percent of Canterbury’s residents had been infected with the novel coronavirus. A third of them were dead.

Sharon Mitchell, a sixty-two-year-old former dental receptionist, was one of the casualties. She had been at Canterbury for two years, following a stroke brought on by the shock of losing her longtime receptionist job, her son Ronald told me. She had been healthy enough to have poststroke rehabilitation therapy at home, but therapists refused to travel to the public housing project where she lived, deeming it too dangerous. So, after much discussion, the family elected to send her to Canterbury (then known as Lexington Court), where Medicaid would cover poststroke treatment.

Even before the pandemic, the facility had a poor reputation. In 2018, a staff nurse was convicted of attempting to rape a seventy-two-year-old Alzheimer’s patient. In October 2019, a report from the Centers for Medicare and Medicaid Services (CMS) cited major staffing shortages and almost three times the number of “health deficiencies” as the national average. By Ronald’s account, Canterbury was “a bad place, a very bad place.” On his weekly visits, his mother told him of “people going to the bathroom on the floor in the hallways” and described Alzheimer’s patients wandering into her room at night. “Her clothes were stolen; her jewelry was stolen,” he told me. The therapy, it turned out, consisted of biweekly sessions in which she was asked to spin a wheel with her hand for fifteen minutes. He was shocked when his mother told him she was given a shower just once a week: “ ‘Thursday’s my shower day,’ she told me. Otherwise they gave her a wipe-down with a baby wipe every two days.”

Unsurprisingly, Sharon routinely contracted hygiene-related urinary tract infections, which led to seizures that sent her to nearby St. Mary’s Hospital. During one of these hospitalizations, a year into his mother’s stay, Ronald spotted blood on one of her socks. Pulling it off, he found that her big toe was infected—it had been neglected by the staff for so long that “the flesh was all eaten away; I could see the bone.” Gangrene had invaded her leg, which eventually had to be amputated above the knee. Immobilized thereafter, Sharon spent most of her time in bed. She was often dehydrated because she could not hold a cup, Ronald said, “but they wouldn’t help her drink, or put her on an IV.”

Ronald saw his mother for the last time in February, before visitors were barred as a precaution against the coronavirus, which had already attacked a nursing home outside Seattle. Two months earlier, Canterbury had been acquired by Tryko Partners, a fast-growing private equity concern, which operated it through an affiliate, Marquis Health Services. A Marquis spokesperson told me that by the time of the COVID-19 outbreak, “in-house staffing was at its highest point in years,” and that wages had been temporarily doubled. But so far as Ronald was concerned, “Nothing had changed. Nothing.” On March 18, a Canterbury patient was diagnosed with the virus. Sharon also tested positive soon after, and was moved into a quarantine unit the center had set up. When Ronald called her after the move, she told him she needed a drink of water. “I stayed on the line for an hour and a half while she pressed the bell for a nurse, but no one ever came,” he said. When he complained, Canterbury staff told him they had just two nurses looking after forty patients. (A Canterbury spokesperson excused the inadequate staffing on grounds that it met CMS guidelines.) Three weeks later, Sharon was dead. “My mom died all alone,” Ronald told me, bitter at the neglect—the dehydration, the pro forma therapy, the gangrene—that he is convinced led to her death. “She was only sixty-two. She was capable of getting better. She didn’t deserve to die like that.”

Months into the pandemic, it has become clear that the majority of people infected by the coronavirus suffer mild or no symptoms and recover quickly. Despite the panic and economic devastation, the risk of death or serious illness from the virus for most people is relatively small. For people of color, it is worse. According to one study, black Americans were more than twice as likely as white Americans to die of COVID-19 complications. But it is worst of all among those with health issues, particularly the elderly. At the height of the pandemic in New York City, for example, fewer than 1 percent of people who died while infected with COVID-19 were confirmed to have lacked an underlying illness.

Inevitably, then, the virus has found its most ideal conditions in the warehouses storing America’s elderly population. No one knows the current death toll. As of early July, CMS put the number at 33,509, but the count covered only federally regulated nursing homes, not assisted-living communities. The homes, moreover, were not required to report deaths that occurred before May 8, although the agency said it was confident that “the vast majority” did so. One in five nursing homes didn’t bother to report their numbers at all. A New York Times study in late June put the number of deaths in U.S. nursing homes at a staggering 55,000, but even this figure did not necessarily include all of those who became infected in a home but died in a hospital, as was the case for Sharon Mitchell. In some states, the vast majority of COVID-19 deaths were in homes: 64 percent in Massachusetts, 68 percent in Pennsylvania, 77 percent in Minnesota. In New Jersey, one in every ten people housed in nursing homes or assisted-living centers died. This was a helpless population, helpless because so often confined in a state of neglect and squalor. But despite or perhaps because of their conditions, they were worth a lot of money. In effect, they were being harvested for profit.

The business model is simple. It depends in part on the personal funds—including insurance policies—of patients or their families, but in larger part on the government programs dedicated to caring for the elderly, Medicare and Medicaid. “It’s a shell game,” explained Doris Gelbman, a Charlottesville, Virginia, attorney who specializes in elder law. “In the first go-round, a patient is covered by Medicare, which pays for treatment and rehabilitation—but only for a limited time. When the Medicare runs out, the patient can either go home, or pay for long-term care.” This can drain away a lifetime of savings in short order, and once it does, Medicaid starts picking up the bill. But Medicaid will only spend a limited amount per patient. (In most of Virginia, including Richmond, the cap is $6,422 a month.) “The only way the home can make it worthwhile and meet their profit target is to cut corners,” said Gelbman. “And that’s why you have low-paid, untrained, and overworked staff.”

Like a flash of lightning, the virus has illuminated a corner of society and the economy that normally festers in obscurity. I asked Mary Evans, a former senior consultant for several leading nursing-home chains, whether she was surprised at the havoc that COVID-19 had wrought in the industry. “It’s not surprising at all,” she said. “It was only a matter of time until something like this happened.” Evans recounted a litany of horror stories, including a Maryland home where unattended patients had uncut toenails “curling around and growing into their feet.” “It’s a nightmare,” she said. “You see why I don’t do this anymore.”

The practice of segregating the elderly in profit-making old-age homes was born in the mid-twentieth century. There were also homes for the elderly in Victorian times, but they were not yet seen as a financial opportunity. The hugely popular nineteenth-century American poet Will Carleton (a frequent Harper’s Magazine contributor) became famous with his 1872 poem “Over the Hill to the Poor House,” which relates the story of a widow left without property and abandoned by ungrateful children who consign her to the miseries of institutional care: “Over the hill to the poor house, I’m trudgin’ my weary way / I, a woman of seventy, and only a trifle gray.” As with the British poorhouses described by Dickens, the grim conditions of their American counterparts reflected the prevailing belief that poverty was in itself a moral failure, and thereby merited appropriately austere treatment. Investigation of one notorious Massachusetts facility revealed, among other atrocities, the deliberate starvation of inmates and the sale of their corpses to medical schools. Most aging Americans avoided this fate by relying on their children to care for them, often sealing the deal with a promise of inheritance. Gelbman summarized this common arrangement: “A daughter would stay home, not get married, and look after the parents as they got old and infirm while her siblings went off and raised families of their own. But in return, she got the house.”

As the Princeton historian Hendrik Hartog explained in his book Someday All This Will Be Yours, this custom persisted into the 1940s, at which point Social Security began replacing the family in providing care and shelter for the elderly. In 1950, an amendment to the 1935 Social Security Act established direct federal payments to privately owned homes, which until then were mostly charities or mom-and-pop operations. (Owing to searing memories of the poorhouses, government aid to any “inmate of a public institution” was explicitly barred.) A for-profit industry was born. Initially the federal subsidies were small, though still enough, according to Mary Mendelson’s 1974 muckraking exposé, Tender Loving Greed, to “whet the appetite” of hustlers who perceived “the exciting profit potential in the nursing home.” These opportunities would expand dramatically in 1965, when the creation of Medicare and Medicaid turned a trickle of federal largesse into a torrent. Medicare financed health care for anyone over sixty-five, and would pay for up to a hundred days in a nursing home for patients recovering from hospital treatment. Medicaid, in addition to providing medical aid to the poor of any age, also provided for unlimited stays in nursing homes. Naturally, hustlers were poised to take full advantage of the near limitless supply of taxpayer money. An Orthodox rabbi named Bernard Bergman built up a nursing-home empire worth some $25 million (while employing Rocco Scarfone, a senior member of the Columbo Mafia family to supervise his flagship nursing home) before being tried and jailed in 1976 for siphoning off Medicaid payments into his own private accounts.

Such examples notwithstanding, the arrival of Ronald Reagan’s business-sponsored administration in 1981 saw a determined effort to dismantle nursing-home regulations deemed irksome by the industry, such as requirements that patients be adequately fed. Retreating in the face of public outcry, his administration adopted the alternative and equally effective course of failing to enforce said regulations. By the following year, according to a report by Kathleen Hughes of Ralph Nader’s Center for Study of Responsive Law, the inspection budget for the agency that oversaw Medicare and Medicaid was so diminished that nursing-home inspections had essentially ceased.

The terms of trade established in the years after 1965—in which cutting costs was favored over improving service—appear to be more or less unchanged. The industry has “no pricing power,” Omotayo Okusanya, a managing director for equity research at Mizuho Securities, explained. “It lives on whatever the government opts to pay.” The art of successful management is thus: “one, control costs, and two, control the patient mix,” meaning ensure that a facility optimizes its ratio of Medicare to Medicaid patients. “Medicare pays more,” said Okusanya—sometimes more than it should. Life Care, a large chain of nursing homes whose Kirkland, Washington, facility saw the first major COVID-19 outbreak, was fined $145 million by the Justice Department in 2016 for “rehabilitation therapy services that were not reasonable, necessary, or skilled.” Such practices are not uncommon. Genesis HealthCare, the largest chain in the United States, paid more than $53 million in 2017 to settle lawsuits by federal law enforcement alleging that its subsidiaries “submitted false claims for services that were grossly substandard and/or worthless.”

In an arrangement that is fairly typical for the industry, Genesis operates homes and manages their services, such as therapy or hospice, but does not necessarily own the buildings or the land they occupy. Until recently, many of the company’s properties belonged to Sabra Health Care REIT, a $3 billion real estate investment trust. Created to facilitate investments in property in the same way mutual funds enable investment in stocks, these companies are relieved of all corporate tax liability provided that at least 90 percent of their income is paid out in dividends. Initially, REITs were only permitted to own businesses that passively collect rent, such as office buildings. Health care facilities, including nursing homes, were excluded from REIT ownership. That changed in 2008, thanks to an intervention by Senator Orrin Hatch of Utah, a trustworthy friend of the nursing-home industry. In July of that year, as financial tremors began to shake Wall Street, Congress passed the Housing and Economic Recovery Act. This measure did little to stem the impending crisis, but buried deep in the legislation was a provision inserted by Hatch, at the urgent request of the REIT industry, permitting them to buy up nursing homes and other health care properties. Demand was brisk, given the growing pool of elderly Americans—known in the industry as the “silver tsunami”—and has remained so. REITs now own over two thousand of the nation’s fifteen thousand nursing-home and assisted-living properties, and their interest in larger properties means their percentage of the total beds is even larger. This makes them especially powerful players in the industry, with returns running significantly ahead of those in other areas of the property market. REITs lease their homes to operating companies such as Sabra and Genesis that are, in theory, entirely independent. Should the operator fall on hard times or into bankruptcy, their losses do not affect the property owner. As Charlene Harrington, a professor of sociology and nursing at the University of California, San Francisco, told me, “It’s all about real estate.”

Genesis itself is under the ownership of private equity, the twenty-first-century answer to Rocco Scarfone. Private equity is the mechanism by which financiers take over a firm using borrowed money and extract as much cash from the purchase as possible—under the guise of “restructuring” it in the form of dividends and fees—before finally discarding the remains either to another buyer or in bankruptcy court. Mitt Romney’s Bain Capital, for example, applied this technique to the once-flourishing Toys “R” Us, destroying the business in a few short years. Beginning around 2004, private equity firms began devouring nursing homes at an accelerated pace. Today, these unregulated groups own or operate one in every ten senior facilities in the country.

The consequences for residents have not been happy. A study published just before the coronavirus onslaught under the auspices of New York University’s Stern School of Business asked, “Does Private Equity Investment in Healthcare Benefit Patients?” In studiously guarded language, the answer was no. Patients, on the other hand, certainly benefit investors. Delving into Medicare data, the researchers found that private equity firms had discovered a variety of ways to recruit more patients, thereby bumping up revenue by 8 percent, which, together with staff cuts, boosted the annual take from an average 110-bed home by more than three quarters of a million dollars. While the average profit margin before taxes for a publicly traded company prior to the 2020 crash was around 10 percent, Evans, the former nursing-home consultant, recalled that the figures for nursing-home firms had more often been between 18 and 25 percent. “They’re very cagey about disclosing this, but that’s what they were shooting for,” said Evans. “They’ll say, ‘Oh, we care about medical care and medical quality,’ but when push comes to shove, they’ll say, ‘We’re losing money hand over fist,’ which means they’re not making their projections. They cry poor so they don’t have to give their employees raises. They operate with barely enough staff. But they make a lot of money.”

One of the principal monsters in the private equity world is the Carlyle Group. In 2007, Carlyle acquired HCR ManorCare, a nationwide nursing-home chain. Four years later, after ManorCare’s debt load had grown from $1 billion to $5 billion, Carlyle hived the company’s real estate holdings off into a separate company, which it sold to a health care REIT called HCP for $6.1 billion, earning its investors $1.3 billion. Under the deal, Carlyle leased the homes back from HCP and continued to extract hefty management and consulting fees from ManorCare, ultimately garnering at least $80 million.

The consequences for the aged and infirm patients subjected to this exercise in financial engineering were sickeningly predictable: crushed by payments on the debt that Carlyle had piled on, as well as $39.5 million in monthly lease payments to the REIT, ManorCare vigorously slashed costs by cutting care for its 25,000 residents. A 2018 Washington Post investigation of the whole sorry saga found that health-code violations reported by Medicare inspectors at ManorCare facilities jumped by at least 26 percent in the years after Carlyle’s purchase. Its debt having climbed to $7.1 billion, ManorCare went bankrupt. (CEO Paul Ormond managed to get away with a compensation package worth $117 million.) Welltower, a $21 billion REIT, bought the real estate at a cost that worked out to $57,000 per bed, a profitable investment given that less than two years later it sold three of the nursing homes for $67 million, or $156,000 per bed. Today, the analyst Okusanya rates Welltower a “buy.”

The strategy employed by Tryko Partners, the private equity operation that runs Canterbury Rehabilitation and Healthcare Center, where Sharon Mitchell spent her last years, appears to be similar to Carlyle’s. Among the thirty other homes it owns is Brentwood Rehabilitation and Healthcare Center, in Danvers, Massachusetts, which it bought for $3.8 million in 2013. By 2015, according to a detailed investigation by Paul Leighton in the Salem News, the facility had been rated “much below average”—the lowest possible category—by Medicare inspectors, who described filthy conditions, overworked staff, and neglected patients. Norman Rokeach, the CEO of Marquis Health Services, Tryko Partners’ health care affiliate, told Leighton that understaffing was due to employees calling in sick or being otherwise unable to work. The $400,000 loss that Brentwood posted in 2015 might have excused the staffing problem but for the fact that Brentwood was meanwhile paying $1.3 million in rent to companies owned by Rokeach and other Tryko principals—effectively draining the struggling facility of resources. (A spokesman at the time claimed, “We’re moving in the right direction. We’re proud of what we’re doing here.”) Four years later, Brentwood is still rated “much below average.” As of mid-June, thirty of its residents were reported to have contracted COVID-19, twenty-two of whom had died.

The pandemic has apparently done little to disturb the industry’s business model. As media reports this spring chronicled soaring numbers of deaths in nursing homes, another ascending graph denoted booming stock prices for nursing-home corporations. After having bottomed out just after mid-March, around the time Sharon Mitchell was diagnosed with the coronavirus, they had been on an upward trajectory ever since. On April 15, the day Mitchell died, the Janus Long-Term Care ETF (market symbol OLD), which reflects the market performance of companies involved in long-term care, was up 38 percent from its low. By June, it had climbed almost 70 percent. Clearly, the crisis was by no means bad for nursing homes, at least not for the 70 percent that are for-profit.

As Okusanya told me, success in the nursing-home business lies in “getting the Medicare-Medicaid mix right.” In March, nursing homes suddenly got a significant boost in Medicare patients. Owing to (another) miscalculation by modelers overestimating the severity of the pandemic and the consequent shortage of hospital beds, New York, Pennsylvania, New Jersey, and other states ordered hospitals to off-load medically stable patients to nursing homes, including people who had been diagnosed with and treated for COVID-19. The nursing homes were required to accept them, and in New York, Governor Andrew Cuomo forbade homes from testing new arrivals. The results were disastrous, as carriers broadcast the virus throughout overcrowded facilities. Once this was publicized, Cuomo and other state executives came in for well-deserved abuse. But for nursing-home owners, there was a silver lining. In October 2019, Medicare instituted a change to its payment systems that made it more profitable for nursing homes to accept Medicare patients from hospitals. According to one analysis, data from April “clearly shows COVID-positive patients generated higher rates than non-COVID patients”—$699 per patient per day, an increase of 9 percent over February’s numbers. Patients were evicted to make room, the New York Times reported, many of whom wound up in “homeless shelters, rundown motels, and other unsafe facilities,” though this has long been a common practice in the industry. Some homes turned into coronavirus-only facilities, including Country Villa South, an eighty-seven-bed Los Angeles home. Well before the pandemic’s arrival, its owner, Rockport Healthcare Services, was sued for allegedly dumping patients without notice to make way for more lucrative replacements. All part of getting the mix right.

As the rising number of nursing-home deaths began generating ugly headlines, industry officials were quick to adopt the roles of both victim and supplicant. “The truth is that nursing homes have not failed America. The public health system has failed nursing homes,” announced Mark Parkinson, the former nursing-home entrepreneur and governor of Kansas who commands the industry’s chief lobbying operation, the American Health Care Association. “Long-term care facilities are doing everything possible to stop the spread of this virus. But we need help.”

That help was soon on the way in the form of the $2 trillion CARES Act. “Here Comes the COVID-19 Cash,” Okusanya wrote in a note to his clients. Nursing homes initially stood to receive $1.5 billion, and further bailout assistance boosted that sum to $5 billion by the end of May. “There are no strings attached,” Seema Verma, the CMS administrator, confirmed at a White House press conference. “So the health care providers that are receiving these dollars can essentially spend that in any way that they see fit.” This was in addition to help provided to the industry in the form of dismantled oversight and regulations. Toby Edelman, an attorney with the Center for Medicare Advocacy, described how CMS had “waived the rule [stating] that homes cannot discharge a patient without notice,” thereby making it easier for nursing homes to dump low-paying Medicaid residents in favor of Medicare patients requiring treatment for COVID-19 at the recently boosted rates. Indignantly, Edelman dismissed recent CMS data indicating that only 3 percent of nursing homes have infection problems (such as the urinary tract infections that sent Sharon Mitchell to the hospital), even as figures from a Government Accountability Office report had revealed dangerous rates of infection at four out of every five homes between 2013 and 2017. “Are we supposed to believe that infections have suddenly almost disappeared?” Edelman asked. Normally, nursing homes are monitored by ombudsmen, licensing agencies, and, most importantly, patients’ relatives. Under lockdown, all that went away. “There’s no oversight,” concluded Edelman. “No infection surveys, no ombudsmen, and no families visiting. I’m really frightened about what’s going on.”

Free from outside scrutiny, the nursing-home industry has been working hard to ward off any future penalties for its treatment of patients during the crisis. This effort has already been handsomely rewarded in a number of states, most notably New York. Deep in Cuomo’s 2020–21 budget is a paragraph providing that, for the length of the COVID-19 crisis,

any health care facility or health care professional shall have immunity from any liability, civil or criminal, for any harm or damages alleged to have been sustained as a result of an act or omission in the course of arranging for or providing health care services.

This neatly lets corporate owners and executives off the hook for any and all mistreatment of their patients. (As reported by David Sirota in Jacobin, Cuomo and the New York State Democratic Committee received no less than $2.3 million from the hospital and nursing-home industries in his frantic effort to ward off an electoral challenge from Cynthia Nixon in 2018. Their faith was apparently not misplaced.)

These immunity provisions, or “get-out-of-jail-free cards,” as Gelbman described them to me, soon spread far beyond New York. As of early July, twenty-one states had adopted immunity laws, each identical to Cuomo’s decree. Uncoincidentally, governors in those states had been in grateful receipt of a total of $44 million in campaign contributions from the nursing-home and hospital business since 2017. Meanwhile, in Washington, Senate majority leader Mitch McConnell was pressing for corporate immunity from coronavirus-related federal lawsuits. Aghast at the prospect of the nursing-home industry escaping accountability, advocates for the elderly rose in protest: “The magnitude of the crisis in nursing homes is directly related to years of cost cutting and understaffing, in an effort to maximize profits for nursing home owners and operators,” a coalition of 250 advocacy organizations wrote Senate leaders. “To allow facilities to face no repercussions for these actions, while asking nursing home residents to pay with their lives, is a perverse outcome that cannot be tolerated.” Nevertheless, as of late June, McConnell remained unmoved, promising a “hard line” and “strong legal protections” for corporations against COVID-19 lawsuits.

The wreckage wrought by the pandemic among the elderly in the United States has by no means been unique. At least half the deaths attributed to COVID-19 across Europe have occurred in nursing homes. In some countries the toll has been far higher—as much as 75 percent in the United Kingdom and 64 percent in Norway. A Dutch nursing-home worker posted a video of himself walking past empty room after empty room, exclaiming, “All the people here died of corona. This whole corridor is dead. Dead.” The same pattern has persisted in Sweden, where the deceased have been almost all elderly. The high death rate in Sweden has been eagerly cited as evidence that the country’s failure to lock down brought inevitably lethal consequences. But Swedes in general escaped relatively lightly, while at least half of those who died were in nursing homes. Another 26 percent were elderly Swedes being attended to at home by overextended care workers shuttling between clients without proper protective equipment, inexorably spreading infection. All of this, though financed by government and local authorities, was managed by for-profit companies. This was true across much of the continent, including in Britain, where nursing homes were privatized by Margaret Thatcher in 1990 and where many have since fallen into the hands of private equity. This pattern suggests that the heavy death toll among the elderly might be traced to one main source: the neoliberal privatization craze that has swept the Western world over the past forty years.

However, an arid statistical table published last year by the World Health Organization suggests a more fundamental truth. It tabulates the number of nursing-home beds per hundred thousand people in each European country. Sweden scores very high—1,276 per hundred thousand. Britain is also high, at 847. The same computation puts the United States at 515. Greece, on the other hand, whose citizens tend not to put their elderly relatives in homes and still regard their care as a family responsibility, scores a mere 15. The disparities in casualty rates are equally striking. In terms of deaths per hundred thousand, Sweden’s rate is 53; the United Kingdom comes in at 66; and the United States has 39. Greece, meanwhile, despite having the largest proportion of elderly people in Europe, has so far escaped with a mere 2 deaths per hundred thousand. One might almost conclude that the death toll that has so traumatized and destabilized much of Western society in 2020 was not wrought principally by the coronavirus, but by nursing homes.

Ideally, we might emulate Greek family relationships and arrangements (or move to Greece to grow old) and abandon the institutional-care approach in favor of a model where the bottom line is not the driving priority. Cedars Healthcare Center is a 141-bed home in Charlottesville, Virginia. It shares many characteristics with the hardest-hit facilities—a population averaging about eighty years old, many of whom are African-American and almost all of whom are on Medicaid. Yet as of mid-June, it had not had a single COVID-19 infection. When I asked how this could be, chief nurse Amy Ryan took me through the relatively straightforward measures the facility adopted in early March, following news of the initial nursing-home outbreak in Kirkland. Cedars discouraged staff from working shifts at other homes, correctly anticipating that such movement would spread the infection. It stockpiled sufficient supplies of protective equipment such as masks. Crucially, it also adjusted the air-conditioning system to prevent circulation throughout the buildings. I asked whether any of these measures had required much labor or investment. “Not really,” she replied. “It was all pretty straightforward. Just getting ready in good time.”

It was hard to see why these precautions could not have been more widely adopted. But there was another factor involved, one less likely to be duplicated. Cedars is part of CommuniCare, a company still owned and run by its founder, Stephen Rosedale, together with his sons, in Cincinnati. Many of the measures adopted by Cedars, such as modifying the air-conditioning, were instituted by headquarters early in March. So far, the chain has largely been successful in curbing COVID-19. Twelve of its eighty-seven homes escaped infection entirely, including some in poor, high-risk neighborhoods. However, it seemed to me that the most important factor was that Rosedale believes that it is important to see things from the perspective of residents and the staff who care for them. Rosedale and his sons have all spent time working as certified nursing assistants, the bottom of the chain of command, very far removed from the financial engineering background of industry supremos.

Of course, nursing-home residents and workers have not been the only vulnerable groups affected by the pandemic. Prisoners, obviously at risk but confined nonetheless, have suffered greatly, as have meatpacking workers, chained to the assembly lines thanks to Trump’s endorsement of greedy corporate pleas that the country would otherwise face a meat shortage (even as exports to China soared). Such are the routinely callous effects of our economic system. But the treatment of the aged stands out. As Simone de Beauvoir once wrote: “By the way in which a society behaves toward its old people, it uncovers the naked and often carefully hidden truths about its real principles and aims.” The virus, it could be said, has made these truths self-evident.

Andrew Cockburn is the Washington editor of Harper’s Magazine and the author, most recently, of Kill Chain: The Rise of the High-Tech Assassins.