Although about 97% of older adults live at home or in adult housing projects, more than two months after the ongoing emergency by COVID-19, the Government has not carried out massive tests to detect the virus among this population. The Government response to serve them has been reduced to, as of June 5, carrying out 6,685 of the 50,000 COVID-19 tests promised for the estimated 28,000 elderly people living in nursing homes, which only house 3% of that demographic group.

Problems such as going to the supermarket, which represents a focus of contagion, access to medicines, going to medical appointments, maintaining hygiene measures and housekeeping, among others, are aggravated in cases where older adults have no family members or formal caregivers (housekeepers) who are available during the pandemic or with a support network that can assist them. For several professionals who serve this population, the reopening of a large number of commercial sectors and the increased risk of contagion represent a double-edged sword for this group.

Don Nicodemus Cuevas lives alone in the Anones rural neighborhood of Naranjito. His children are not in Puerto Rico, so at 82 years-old he runs errands, picks up his medications, cooks his food and does his shopping, a routine he has maintained despite the risk of COVID-19.

“Not a soul has come here to help me. I live alone, my children are in the United States. I have neighbors nearby, but they’re as old as me. Do I take care of myself? Of course, I take care of myself!” He said with a laugh when the Center for Investigative Journalism (CPI, in Spanish) asked him if he has gotten help on his errands or any help from the Government during this emergency.

People from a church in Toa Alta delivered groceries to him during Holy Week after he called a lawyer, fearful that he would run out of food after hearing on the radio that businesses would be closed for several days following an order from Gov. Wanda Vázquez. That was the only help this veteran has received.

“[There’s] so much aid for the elderly and veterans. They haven’t given me anything. The only call I got was from Veterans [Administration] was to cancel my appointment…nothing else,” he said.

More than two months after the lockdown and in the midst of a commercial reopening, the Government’s strategy is limited to establishing a protocol for rapid tests in long-term care centers where only 3% of older adults reside, leaving nearly 844,000 citizens over 60 years-old exposed because they have to do their shopping and errands risking themselves to a possible spread of coronavirus when visiting stores, hospitals and drugstores.

“I worry about the older adults who live in the community, who have no choice but to go out to do their shopping and who are exposed to the virus. Those are not being tested,” said José Acarón, executive director of AARP, Puerto Rico.

According to data from the US Census Bureau’s 2017 Community Survey, the island’s elderly population is 843,829 people, representing 24% of the general population. Of these, it is estimated that only 28,000 live in long-term care centers (the so-called nursing homes or elderly homes) where a plan to test residents and employees for COVID-19 was activated on April 19. The initiative was created by the US District Attorney’s Office and the US Government’s Elder Justice Task Force (EJTF).

They die without being tested

According to information from Puerto Rico’s Mortality Database, delivered on May 21 and which has a data entry lag of several weeks, of the 92 deaths attributed to COVID-19 as the main cause of death, 74 correspond to people 60 or older. In addition to these 92 deaths, there are 19 others that identify COVID-19 as a secondary or complementary cause — 14 of them are older adults.

Of the total 111 deaths that list COVID as the main or complementary cause, only one of these deaths occurred in a nursing home or long-term care institution. A total of 103 deaths occurred in a hospital facility, either from hospitalization or during an emergency room visit.

One of these cases is that of Doña Rosa, whose fictitious name seeks to protect the details of her case. Her granddaughter still cannot understand the situation her family experienced since March when her grandmother, in the 80s, began to show coughing and respiratory problems and was treated for mycoplasma. The woman was not tested for influenza, mycoplasma, and much less COVID-19. Several weeks later — on March 24-25 — Rosa’s medical condition began to worsen. She stopped eating and talking.

Due to her health conditions, her doctor decided not to take her to the hospital until she received the results of the influenza and mycoplasma tests, which came back negative. The same day that she was going to be transferred to a hospital in Bayamón to test her for coronavirus, Rosa woke up with serious respiratory problems, so her family decided to call an ambulance to take her to the emergency room. Her condition had worsened to the point where she was keeping her mouth open gasping for air between short breaths, her granddaughter explained. Rosa died shortly after arriving at the hospital, where she was treated as an emergency patient with respiratory failure.

“She wasn’t there more than two hours, since she died in the hospital that same day, on March 26, while they tried to stabilize and intubate her,” her granddaughter, who recounted the ordeal her family experienced, told the CPI. under the condition of keeping their identity confidential while several complaints are pending. She said it was the family members who asked the Bureau of Forensic Sciences (NCF, in Spanish) to do the COVID-19 test. Rosa’s body had been transferred to the NCF because she had not been formally hospitalized, dying two hours after arriving at the hospital.

While relatives waited for the forensic result for Rosa’s wake, her husband, Don Antonio, who for weeks experienced symptoms of persistent cough, sore throat, body aches and respiratory problems, worsened and was taken to the same hospital in Bayamón. Since he did not have a fever, the hospital did not test him for COVID-19.

“My mom told me that in the hospital they apparently thought he was depressed because of the loss of his wife and that caused him to feel sicker than he was. My mother asked them to please do the test, and they told her that since he didn’t have a fever, they couldn’t do the test,” she said.

According to the granddaughter, on April 1 the relatives held Rosa’s wake after receiving authorization from the NCF. That same day, the Department of Health reported a woman the same age as her grandmother, who had gone in critical condition to the emergency room in a hospital in Bayamón, where she died, and who yielded positive when tested after passing on. However, Rosa’s family was not notified that her relative had tested positive for COVID-19 until several days after the wake took place.

“We understood that if we had been authorized to conduct the ceremony, it was because my grandmother had tested negative. It wasn’t until April 3 that my mother was notified that my grandmother had tested positive for COVID. I don’t remember if it was the funeral home or the [Bureau of] Forensic Sciences. The protocol of cremating the body wasn’t followed, as the Government said should happen if the person tested positive for COVID-19. We had to call the family to try to get all [the relatives] tested. One of my aunts tested positive, as well as my 10-year-old son,” she said.

While all this was happening, Don Antonio was getting worse. They had already done a test for COVID-19 but it came back inconclusive and he was waiting for the molecular test. But on Saturday, April 4, he returned to the hospital by ambulance and was tested for the second time for influenza and mycoplasma. They sent him back home that same day since he could not be tested for COVID-19 because it was a weekend. At the hospital they were told that the sample could be lost and, besides, he was not hospitalized.

It was not until Monday that they performed the molecular test at his home where he remained through Friday after — for the third time — family members took him back to the hospital because his medical condition was worsening, and they did not know if he was positive for COVID-19. According to his granddaughter, it was at the hospital that the medical staff conveyed the results of the analyzes: Don Antonio, 87, not only had pneumonia, his heart was already failing, and he had also tested positive for COVID-19.

“The family went through all this…we found out about my deceased grandmother’s positive [result] through the news — first no, then yes — and the anguish for weeks over my grandfather’s condition until he was finally hospitalized by COVID-19. We never found out who gave the authorization for the wake when my grandmother had tested positive exposing other family members,” the granddaughter of both older adults said.

She said the family is not sure how their grandmother got it. They think it could have been during her visits to the hospital to take care of other conditions, but on the other hand, Rosa’s caregiver’s husband died from the coronavirus and had contact with her at least three times while he was ill, not knowing he was infected. The caregiver never presented symptoms and later she tested negative for COVID-19.

There’s no Government strategy to protect adults

The AARP and the Bar Association’s Commission on Elderly Rights agreed there is no public policy for guidance, tracking or individualized attention aimed at protecting the thousands of older adults living alone in their homes, many of them with medical conditions, forcing them to depend on caregivers, scientists and professionals who offer services to the elderly also agreed. They are not on the government’s radar, which is evidenced by the lack of statistics and information about where they are located.

On April 19, the National Guard (GNPR, in Spanish) confirmed it had coordinated visits by military personnel, jointly with the 330 Centers, to nearly 1,000 homes for the elderly, to administer both the rapid test and the molecular test to residents and employees of those homes. Since these visits began almost three weeks ago, the GNPR has reached 59 homes where just 3,492 rapid tests and 3,193 molecular tests have been done, of the 50,000 the governor announced on April 19, representing 13% of the total tests promised.

The Department of Health provided those rapid tests for use on “about 28,000 residents and 9,000 employees in 1,000 long-term care facilities.” It was said in the initial announcement that, with the help of National Guard personnel, they expected to conduct all of the tests in a three-week period.

“So far, the project is only for long-term elderly care centers. This is the information that the 330 Centers have,” said the president of the Puerto Rico Primary Health Association, Alicia Suárez Fajardo. It is not expected to expand to include the elderly homes, which are independent senior housing complexes.

She said that during the home visit program carried out by the 330 Centers, they are administering COVID-19 tests in private residences, but only if the doctor who is visiting that private home orders it. This initiative is completely independent of the Direct Relief project with the elderly centers.

Beyond carrying out this minimum number of rapid tests in the elderly centers and the initiative to distribute food through the centers, authorities have not developed an action plan to meet the multiple needs of older adults, a sector that represents 24% of Puerto Rico’s population, health professionals and the heads of organizations specializing in elderly services agreed.

The Elderly Task Force initiative falls short of the needs of an older adult population that mostly lives alone, with their spouses, or in single-family projects. Contrary to residents in nursing homes, this population is the one that is most exposed to meet their needs, several professionals dedicated to serving this group agreed.

In spite of being at greater risk, the absence of an effective direct support network and an orientation and monitoring plan for measures to avoid contagion, makes them invisible in the State’s protocol, not only for the administration of COVID-19 tests and food distribution, but also to supply them with the most basic needs of attention, hygiene and even medical care with the sensitivity that this population deserves.

“The Government has focused on carrying out tests to detect the lethal virus in long-term care centers, leaving the rest exposed,” denounced Gerontologist and Social Worker, Dr. Astrid Santiago Orría.

“There is no coordinated policy for the guidance, tracing and care of older adults without considering their vulnerability to COVID-19,” said the gerontologist, upon hearing the cases of Doña Rosa and Don Antonio.

Older adults at real risk for COVID-19

Carmen Ortiz, 69, has received neither food nor government aid. She lives in Luquillo with her spouse, and since the quarantine began, she is responsible for the household shopping for groceries and medicines.

She gets a $25 monthly food voucher from the health insurance company MMM. And once a month, she goes to the supermarket taking all the precautions to buy groceries, which she then shares with her daughter and grandchildren.

“I go alone. I get up at 4 a.m. and take off at 5 a.m. so that there aren’t many people. I do my errands and I come back quickly. I go with my gloves, my mask, carry my hand sanitizer and everything. I don’t go out to the supermarket and the drugstores to get my medicines unless it’s necessary. From there on out, I go nowhere else,” she explained.

She admitted it is tiring, but she prefers to do her shopping because she feels capable; she has no medical conditions “beyond the thyroid.” Although stores have opened, she said she has not visited them. They also haven’t had family gatherings, which she confesses has been tough.

“We haven’t been able to spend time together. We talk on the phone. Not even on Mother’s Day…,” she said.

The Government has not established a massive targeting campaign aimed at the protection, security, and care of the most vulnerable population and those at greatest risk of contagion in the face of the economic reopening.

“I think the most important thing is to recognize that in spite of the fact that people 60 years of age or older only represent 28% of those infected, they are almost 80% of deaths. The risk, statistically speaking, is 10 times greater of dying if you become infected when you are over 60. Someone older, retired possibly gets sick by coming into contact with someone who decided they weren’t going to follow the protection measures. There’s a need for social commitment,” said Epidemiologist and Statistician Luis Manuel Santiago Bibiloni.

“It’s very important that the help and the phone numbers are published. What efforts are being made to spread this information at the community and municipal levels? We have the digital gap. [Older adults] aren’t going to have a smartphone, nor are they going to have Facebook. We have people who are older adults who have no relatives and need that assistance. There are efforts like the [community] centers, but not everyone participates. And others who don’t have transportation in remote places and residing alone,” Attorney Giselle Lombardi, president of the Puerto Rico Bar Association’s Elderly Rights Commission stated.

Meanwhile, Santiago Bibiloni proposed that, given the Government’s lacking response, it is up to the community to become active in watching out for the elderly who live in their neighborhoods and become their “informal caregivers” helping with their shopping, helping in hygiene and cleanliness, as well as buying medicines, and taking them to medical appointments. He also proposed a community program to “adopt an elderly person.”

“Aside from the limited effort to provide more tests to nursing homes, I haven’t seen an approach toward elderly people who live alone. What’s the use? That’s the purpose of my program: ‘Adopt an Elderly Person.’ Many times, we forget about the human factor. They are very old people who go out to buy for the day. They keep going out daily. But if we had a plan…They need help and the community must assume the responsibility that the Government has not assumed. The answer is from the bottom up. We are saturated with numbers and we must give it a human face,” he said.

Santiago Biblioni’s proposal coincides with the vision of Dr. Mark Grabowsky, expert in disease prevention during a webinar coordinated by Filantropía Puerto Rico. Grabowsky argued that “We would need more rigorous measures, particularly in higher risk groups.” He cited a study by David L. Katz of Yale University that proposes strict measures for older adults who, if they have chronic illnesses, must maintain social distance in strict confinement at home and have zero contact with family members.

No protocol to administer tests in nursing homes

The absence of a protocol specifying how the process will be carried out in these homes and long-term care facilities, which three sources confirmed to the CPI, raises questions about what measures will be taken to protect the health of older adults living in these institutions.

“The Department of Health is the one leading this effort,” Puerto Rico National Guard Adjutant General Juan Reyes told the CPI when asked why no more elderly homes have been reached. He also said the Government hired the Quest and Toledo laboratories to work on the plan.

Administration of the rapid tests at the elderly centers began on Monday, April 20, a day after the initiative was announced. The plan called to visit three homes for the elderly that day, Reyes said. However, only two could be reached and 200 tests carried out on residents and employees.

“The coordination wasn’t the best,” explained Reyes.

When the National Guard spokesman was asked about the existence of the Department of Health’s protocol to conduct the initiative, the military officer said he believed the agency would be disclosing it on Thursday, April 23. The CPI requested the document from the Department of Health three times as of April 22, but the efforts were unsuccessful.

“It’s something that we discussed with the Department of Health’s staff. That’s why we have not carried out this mission aggressively. The homes that were worked on Monday [April 20] were those that requested services from the [Elder Justice] Task Force and the Department of Health,” Reyes said admitting that at the beginning of the initiative there was still no protocol from the Department of Health to handle the administration of COVID-19 tests in nursing homes and long-term care facilities.

As an initiative of the US Government through the Federal Prosecutor’s Office and the EJTF, the CPI contacted the Federal Prosecutor’s Office for Puerto Rico District to ask about the existence of a protocol. They were asked if the federal government also participates in the development of the protocol, in addition to the Puerto Rico Department of Health.

“We continue to fine-tune protocol and assist in inter-agency coordination and follow-up on data and daily reports,” was the response that the Federal Prosecutor provided on behalf of the EJTF Coordinator, Assistant Federal Prosecutor, Jacqueline Novas.

It was not until Tuesday, May 19, that the Department of Health finally sent the CPI a three-page document that presents diagrams about the agencies involved in the initiative and the steps to be taken depending on the test result. The document does not include explanatory paragraphs, it lacks a title or heading, nor does it indicate who produces it or to whom it is addressed. The health and safety measures that will be followed when going to administer the tests at the elderly centers are not explained either.

The lack of this information as part of the initiative to administer tests at the care centers has raised concerns among people who work with this population, including those who run these institutions. One of the questions posed to the CPI is how measures will be taken to prevent medical and support personnel visiting various centers from infecting residents and staff at elderly homes where no suspected cases of COVID-19 have been reported.

“They’ll go to every (elderly) home, but if there was a case in one of them, then there are people who will say they don’t want them to come to mine (home) because they have already been exposed,” the President of the Association Long-term Care Center Owners, Juanita Aponte, who in turn runs the Hogar Lomas San Agustín in Río Piedras.

According to Aponte, the danger of contagion of its residents is represented by people who constantly come and go to these care facilities. Older adults never leave the centers and family visits have been prohibited since the emergency began.

“I asked them to bring me evidence that those who come to do the tests are negative [to COVID-19] so that they don’t infect my residents. In a certain way, I’m concerned that I’m assuming the responsibility for mistakes they make,” said Aponte, who advocated a protocol that includes a responsibility waiver for care centers owners in case their residents are infected with COVID-19 by those administering the government tests.

Although the Department of Family released the Guide for the Prevention and Control of COVID-19 Infections in Long-Term Care Facilities for Older Adults on March 31, that document does not address the issue of testing for the virus.

“What’s the plan? Who will be the staff in charge of informing the center managers about the protocol? Is it more convenient to train a person in the institution to do the tests when there are suspicious cases?” the president of the Brigada de la 3ra Edad, Amada García Gutiérrez asked, reflecting on the need for a protocol that outlines the security measures.

Faced with these questions, the General Assistant of the National Guard admitted that said concern is valid. However, he said that the administration of the tests will be voluntary, and up to the elderly care centers.

“It certainly is a concern. If we start evaluating it, we don’t want what has happened in elderly centers in other states to happen to us,” Reyes said, referring to the high number of deaths. According to research published by AARP, more than 38,000 people, including older adults and workers, have died in long-term care facilities for the elderly in the United States. That figure represents approximately 25% of COVID-19-related deaths in that country as of June 1.

Half of the deaths attributed to COVID-19 in Europe were registered in nursing homes, the World Health Organization reported. According to statements by WHO regional director for Europe, Hans Kluge, the high number of infections and deaths in long-term care centers underscore the need for their services to be managed safely and for staff conditions to be improved.

Rafael R. Díaz Torres is a member of Report for America.