Experts and advocates warned for years that chronic understaffing, precarious working conditions, and poor workplace safety at nursing homes put Ontario’s vulnerable elders and the workers who care for them at risk. Now the COVID-19 pandemic is exploiting those flaws.

At least eight nursing and retirement homes in the province are battling outbreaks of the coronavirus — including one in a Bobcaygeon facility that health officials have called the largest outbreak in the province. Thirty-five residents at the home are showing symptoms and two have died, with warnings more deaths may come.

At least seven of Ontario’s 18 reported coronavirus deaths have been residents of long-term-care or assisted-living facilities. That number, and the number of outbreaks, come from media reports and information from regional public health units. The Ministry of Health and Long Term Care has not publicly released information on the number of nursing home outbreaks and did not respond to requests for comment.

While staff work furiously to protect residents, they are doing so in an understaffed system where some workers have little support or stability — problems experts say have persisted despite longstanding calls for reform.

Nursing homes are “ground zero” for the COVID-19 pandemic, researchers warn — and have been particularly susceptible in the past.

A 2005 outbreak of Legionnaires disease at one particular Scarborough long-term-care home was held up by the panel of experts who investigated the SARS crisis as a devastating example of the regulatory “failure” and workplace safety lapses that led to the spread of disease amongst 130 workers, residents and visitors. Some 23 residents died.

Now, nearly two decades later that same facility — Seven Oaks — has seen nine residents and seven staff infected by COVID-19, according to Toronto Public Health. Two residents have died.

Ontario is not alone in confronting the COVID-19 pandemic’s brutal toll on the elderly. In China, the fatality rate for confirmed cases under the age of 50 is less than 1 per cent, but for those over 80 it is nearly 15 per cent, according to data published in the Journal of the American Medical Association (JAMA).

In Italy the virus slammed seniors even harder, fatal in more than 20 per cent of cases over the age of 80. Italy’s significantly older population is suspected to be one reason why the country has experienced a much higher death toll than China, despite similar overall case totals.

Researchers writing in another JAMA article said nursing homes are likely to become “hubs in their communities for the worst” outcomes of COVID-19.

The older, frailer demographic living in nursing homes is part of their vulnerability. But the inherent structure of the facilities, with many communal spaces and people moving among them, also plays a role, says David Grabowski, who co-authored the JAMA commentary.

“It’s not a medical facility. Home is right there in the title — they’re going to have visitors, they’re going to have meals together, they’re going to live their lives,” says Grabowski, a professor of health care policy at Harvard Medical School.

Visitors have been restricted in Ontario long-term-care homes, and both staff and essential visitors are screened for symptoms and travel history. Some facilities are limiting communal activities even in sites without an outbreak.

But structural staffing problems are also a big reason nursing homes are vulnerable to COVID-19, and those are much harder to overcome.

“That’s not to say that nursing homes don’t do a good job. The staff there are incredibly vital, in fact oftentimes the most important in the day-to-day welfare of these individuals,” says Grabowski.

But the precarious, “fluid” nature of these workers increases the risk of transmission, he and other experts say. Many are paid low wages and work part time, requiring them to bounce among facilities to patch together enough income, potentially spreading the coronavirus to multiple locations.

Monique Langlois, a member of the Ontario Personal Support Workers Association who is employed in a Windsor-area nursing home, said most facilities don’t hire full time — leaving workers with “no choice” but to work for several.

Working in a single nursing home would only be possible if workers could stomach working “mornings, afternoons, and nights, all in one week,” she added.

“The hours are always available if you’re willing to kill yourself, basically,” she said.

Ontario’s chief medical officer of health issued a directive to long-term-care homes last Sunday that asked employers to limit the number of different work locations for staff “wherever possible” to limit the transmission of the virus.

“The challenging thing is that before this COVID-19 pandemic happened, we were already suffering from a health human resources crisis in long-term care, and we already had many homes working without enough staff,” says Lisa Levin, the CEO of AdvantAge Ontario.

Many workers are now off because they’re in isolation or ill, and half of long-term-care employees are already part-time, Levin says.

“By outright saying that staff cannot work in more than one health-care setting … it could cripple the system in terms of staff.”

Levin added that her association, which represents not-for-profit, charitable and municipal homes for seniors, had asked successive governments over many years to increase funding in order to improve staffing levels at long-term-care homes.

Levin also said nursing homes are currently suffering from serious shortages of masks and other personal protective equipment.

One Toronto-area PSW, who asked not to be identified for fear of reprisal, said her primary employer has instructed caregivers not to work for multiple companies. But as a home-care worker, she still visits multiple residences a day — making less than $18 an hour, with no protective equipment like gloves or masks provided until late this week.

She said she’s not surprised that nursing homes have become the epicentre of the COVID-19 outbreak — based on previous outbreaks caused by workplace hazards.

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“There needs to be more maintenance and vigilance on stuff like that, instead of the bottom line,” she said.

But confusion over who is responsible for preventing the spread of disease — and how — is a persistent issue.

In the wake of the 2003 SARS crisis, a commission tasked with investigating Ontario’s response painted a damning picture of workplace safety lapses — and the critical role of the Ministry of Labour’s intervention in containing disease outbreak.

The commission found that directives to keep workplaces safe during SARS were “prepared without appropriate oversight by the Ministry of Labour.”

It found that enforcement was ineffective, if not non-existent: the ministry did not conduct any proactive inspections at SARS hospitals for “virtually all the outbreak.”

It found that despite its legal mandate to protect workers, the ministry was “sidelined” for the duration of the crisis, amid a “turf war” between labour and health officials.

And it found that those issues came back to haunt both — at Seven Oaks Home for the Aged.

Two years after the SARS outbreak, Seven Oaks was thrown into turmoil when an unidentified illness began killing residents. It took days for experts to pinpoint the cause: Legionnaires disease. The illness infected 70 residents, 39 staff and 21 visitors. In total, 23 residents died.

Unlike SARS and COVID-19, Legionnaires disease is spread through contaminated water sources, not person-to-person contact. Under provincial health and safety laws, employers are required to prevent workers’ exposure to the illness — for example through proper maintenance of water and ventilation systems.

Despite those legal obligations, the SARS commission found the response to the Seven Oaks crisis “lacked sufficient involvement of the Ministry of Labour and of independent Ontario worker safety experts,” compromising the health of frontline staff — and by extension, those in their care.

Without “recognized, mandated and enforced” workplace safety precautions, the commission warned, “nurses and doctors and other health workers will continue to be at risk from new infections like SARS.”

But Jim Brophy, an occupational disease expert focusing on the health-care sector, said the labour ministry is still “missing in action.” Workplace injury and illness rates in nursing, retirement and group homes are significantly higher than in other health-care settings — as well as the provincial average.

“The system has been broken for a long time,” said Theresa Armstrong, an Ontario New Democrat MPP and the party’s critic for home care and long-term care.

“If we protect our workers we’re going to protect our residents, our family members.”

Following the recent COVID-19 outbreak at Seven Oaks, Ministry of Labour spokesperson Janet Deline said inspectors responded to a complaint last week that a resident had tested positive for the virus.

No health and safety orders were issued and the investigation is now complete, Deline told the Star.

As of Friday, nine residents and seven staff at Seven Oaks have been diagnosed. Staff have been directed not to move among different facilities. Toronto Public Health spokesperson Dr. Elizabeth Rea said the home has implemented the necessary protocols to prevent further virus spread, including enhanced cleaning regimens and use of personal protective equipment by caregivers.

An outbreak is declared when there are at least two COVID-19 cases in a facility, health officials said. In addition to the eight outbreaks the Star is aware of, at least 10 others have a single case.

At nursing homes where there are no recorded outbreaks, the broader workplace problems remain, says Winnie Ng, a labour scholar focused on precarious work and an adjunct professor with Ryerson University’s School of Social Work.

“The level of care was already deficient and workers overworked prior to the outbreak of COVID-19,” she said.

“Now the pandemic has just exacerbated the substandard level of care and put the lives of the residents and their care workers in further jeopardy.”