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A resident (left) of the Domenico Sartor nursing home in Castelfranco Veneto, near Venice, hugs her visiting daughter; Photo: Piero Cruciatti/AFP via Getty Images (Whitehead 2020)
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Prof. Darja Zaviršek,
Chair of the Dept. of Social Justice and Inclusion University of Ljubljana; President of the East European Sub-regional Association of the Schools of Social Work, EEsrASSW of the IASSW; IASSW board member

There is no such boat as Noah's Ark in the SARS-CoV-2 pandemic: elderly women in Slovenia during Covid-19

People are never 'in the same boat', and some people and some regions were more affected by the global pandemic than others. Moreover, social workers are perceived differently in different countries, have different status, and influence on decision-making and disaster management processes in times of emergencies. It was promising news that at the end of the first year of the pandemic in the UK, social workers were granted the status of an 'essential profession'. In Slovenia, government agencies mitigating the effects of an epidemic seek advice from doctors, epidemiologists, business economists and engineers, but social workers have not been invited to be part of the "emergency response boat." Nor did social workers demand to be part of it. What did we learn during the pandemic about the society in which we live and about the status of social work?

The spread of Covid-19 and deaths among older women in congregational settings

Many post-socialist countries, such as Poland, Czech Republic and Slovenia, are among the countries with the highest number of Covid-19 infections and deaths in Europe. In some countries with high numbers of Covid-19 positive people, such as Bosnia and Herzegovina, the government has not yet started vaccinating people. In most countries of Eastern European there is no rapid self-testing. During the lockdown, women carried a heavy burden of the medical and social crises; they stayed at home, helped children with schooling, cared for relatives, cleaned and cooked, and continued to work in paid employment. They also worked extra hours in dangerous environments in hospitals, homes for the elderly, the disabled, or in rehabilitation centres for Covid-19 survivors, where the majority of staff among nurses, caregivers, and housekeepers are women.

During the first and partly also the second lockdown in 2020, most deaths in Slovenia occurred in old people's homes (80% of all deaths) and in other long-term social protection institutions, despite the complete closure of these social institutions. In old people's homes (usually facilities with 120 to 600 beds for residents aged over 65), most residents are women (Božič-Verbič 2019). It is worth noting that deinstitutionalisation of large (public and private) institutions with long length of stay has not yet taken place. In the country of Slovenia with a small population (2 million people), more than 24,000 people live in congregational settings, of which 19,000 live in homes for the elderly.

The figures show that the Covid-19 virus does not affect all elderly people equally, but mainly those living in large long-stay residential facilities. Elders who live at home were not affected by the Covid-19 so much. Due to the lack of protective clothing, rapid testing, and due to the high density of people (residents and staff) coming into close contact with each other many times a day, infections spread rapidly among elderly women living in congregational facilities. The predominantly female work staff were also infected and became ill, but in smaller numbers than the residents themselves. Although the women were confined to their rooms (usually two women live in one room) and were not allowed to use the living quarters, garden and corridors for walking and social contact, nothing prevented the spread of the virus.

When the number of people infected in the old people's homes began to grow, the main government measure to stop the increase in infections was to seal off the facilities completely from the outside world. In two old people's homes, the management even decided to build a wall to prevent anyone from approaching the homes' windows (Zaviršek, 2020). Some elderly women who could, waved to each other and to relatives from their room windows and balconies for long months. Those who could not, saw their loved ones once a month and sometimes more often for a few minutes via Skype.

There was a fear that hospitals in Slovenia would soon be filled with younger Covid-19 patients and unable to respond to all the demands of people who needed hospitalisation. It seemed that fear, unpreparedness for the epidemic, and lack of understanding of human rights led to the decision that the infected and sick elderly from long-stay institutions should not be transferred to hospitals but shall be treated in the nursing homes (Jager 2020; Kovač 2020).

It is important to emphasise that the old people's homes are not medical but social protection institutions, which have a notorious shortage of staff and are understaffed with medical professionals, doctors and nurses. Most female staff have basic education and are poorly paid (slightly above minimum wage). In some nursing homes, a doctor works only a few days a week or even less. The long-stay institutions for elders in Slovenia are also not palliative in nature and people are not divided into "palliative patients" and active residents.

Without the informed consent of the individual residents and without informing their relatives, a "special commission" came from outside and divided all the residents from 102 old people's homes in the country into those who should be actively treated in hospitals and those who should not be given hospital treatment. The decision was made on the basis of each person's medical records. Each nursing home kept a list, which later became known as the "Register of the Written Offs" (Keber, 2020). With hindsight, it has become public knowledge that the process was not transparent and not based on sufficient ethical considerations and standards, and that various professional groups were not consulted to give their expertise in line with their codes of conduct. In addition, during the first lockdown, hospital facilities in Slovenia that were prepared to receive patients with severe symptoms of Covid-19 virus were quite empty. Only one third of all beds reserved for Covid-19 patients were occupied (Republic of Slovenia, National Assembly, Health Committee 2020). In turn, nursing homes are usually overcrowded and fully occupied, so there could be little space for proper isolation of Covid-19 positive individuals, and even less for those who become ill.

In social welfare institutions such as nursing homes, the profession of social workers has an important role to play. Social workers are the intermediaries between life inside and life outside the institution; they are the intermediaries between the residents and the relatives and they are expected to work as advocates for the elders. The Global Social Work Statement of Ethical Principles (IASSW) emphasises that social workers recognise people as capable and self-determining; that they promote people's rights to make their own decisions and that they promote the right to self-determination. During the processes described above, social workers were not consulted and were not part of the selection process of who would be taken to the hospitals and who would not be taken to the hospital in Covid-19 emergency. Were the social workers aware of these decisions and were they able to identify the unethical practise? Were any of the social workers acting as whistleblowers? Some of the social workers certainly advocated for more humane treatment of the isolated people, but whether social workers spoke out against such a practise is not known.

From a social work and gender-conscious perspective, we need to ask whether agism and sexism intersect in this particular emergency situation? Are women who cannot work, reproduce, and care for others less worthy of receiving appropriate medical treatment? After July 2020, the 'Register of the Written Off' was condemned by the media, public intellectuals, various social care actors such as the Older People's Advocate and the Association of the Social Protection Institutions.

Lessons to be learned

Residents of various public and private long-term care facilities, mostly women, have been admitted to public hospitals since the unethical practise when they show symptoms of Covid-19. Unfortunately, no one has been held accountable for the decisions made in the early days of the epidemic and especially between March and May 2020. It may be too early to begin reconciliation and trauma work.

Society in Slovenia has learned the lesson that intergenerational solidarity is not self-evident and that "age" is also gendered. Younger women are structurally disadvantaged when they are ascribed the responsibility for paid and unpaid work, biological reproduction and family. Gendered inequality continues as women grow older and have no right to self-determination to choose with whom and how and where they want to live.

The lesson learned is also related to the issue of triage, which is not only a medical issue, but also a social issue. Triage is used in situations where, due to disasters and crises, not all people who need medical treatment can receive it, so different agencies in countries decide what the criteria are for who gets the treatment they could benefit from and who doesn't. Social workers know that medical and social criteria overlap and that health is a social and human rights issue. Therefore, it would be important to include the issue of triage in social work debates when discussing ethical dilemmas and values in social work education. Apart from medical criteria, the triage system must be based on values, transparency and the promotion of justice. In the case of Slovenia, age and gender stereotypes influenced the application of the opaque medical criteria. Apart from the lack of transparency, the involvement of the people who are the actual "subjects" of these decisions are one of the important social work principles. The lack of guidelines on justice and ethics needs to be always a social work concern. It seems that the pandemic demands new topics to be taught during social work education.

There is never enough discussion about ethical standards in social work practise. It is important for social work practise to actively involve residents of long-term care facilities and their families in important decisions, including decisions about their medical treatments.

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Hug Room in Milan Elders Home (Anonymous 2020).

Creativity is urgently needed in these times of lockdowns. Are there ways to support people who have the restrictions of movement in long-term care facilities during an epidemic and address their diverse needs? One of the best practises came from Italy, where staff at a nursing home in Castelfranco Veneto near Venice installed plastic curtains that allowed residents and visitors to hug each other and have greater physical closeness than usual during the pandemic (Whitehead 2020; see Photos 1 and 2).

In the post-pandemic period, there need to be an opportunity to reflect on institutional life and encourage the deinstitutionalisation processes of community living rather than congregational settings of long-stay large institutions. Women in the past did not have a "room of their own," to recall the famous words of Virginia Wolf, and therefore many could not be as creative in writing, composing, and painting as men. Today, every woman who grows old should have a "room of her own" if she chooses to live in a community-based residence home.

In a pandemic disaster, social workers are as important as medical doctors, business economists, and engineers. Government emergency expert groups on prevention and mitigation have to include social workers, disability activists and other key professionals to make holistic, human rights-based and people-friendly decisions. Social workers must not be the silent bystanders when unethical practises happen but need to raise their voices as per the ethical standards of the profession.

References

Anonymous ( 2020). Covid-19: Italian nursing home creates Hug Room. Wanted in Milan. 12th Nov. wantedinmilan.com/news
Božič Verbič, Ana (2019). Almost one in five inhabitant living in Slovenia is older than 65 year. Statistical Office of the Republic of Slovenia. 23rd September. stat.si
Jager, Vasja (2020), In the institutions exist the registers of the written offs, who are not allowed to come to the hospital, Mladina, 15th May 2020. mladina.si
Kovač, Vanja (2020), The decision to keep the ill and infected in the institutions foe elders was bad and has tragical consequences. MMC RTV SLO, 23rd May 2020. rtvslo.si
; Keber, Dušan (2020), It is about Humanity. Dnevnik. 13th June.
Republic of Slovenia, National Assembly, Health Committee (2020). 37th emergency meeting and Committee of Labour, Family and Social Affairs and Disabled People and 40th emergency meeting. 9th June. dz-rs.si
Whitehead, Joanna (2020), Italian care home installs plastic curtains for residents to cuddle loved ones. Independent.13th November. independent.co.uk
Zaviršek, Darja (2020), Solidarity and cruelty in the times of Corona crises. Dnevnik, Ojektiv, 11th April, Year 70, no. 85. dnevnik.si