WHO Country and Technical Guidance – COVID-19: Analysis of the Focus on Older People
Global Effects of COVID-19
Since the onset of the COVID-19 pandemic, older people have been recognized globally as one of the most vulnerable population groups. Older people are not only vulnerable to contracting COVID-19 with severe consequences, including death, but they are also vulnerable to debilitating consequences resulting from systemic ageism around the world.
The International Federation on Ageing (IFA) recognizes the need for a strong and coordinated international response through the leadership of the WHO and other international partners. The IFA recognizes the dynamic nature of the pandemic and learnings required on a moment-to-moment basis. In an effort to support the further development of targeted guidelines, the IFA has sought to understand where and how the unique needs of older people are being addressed in technical guidelines.
COVID-19 and the Rights of Older People
In these unprecedented times of crisis, advocates for the protection of the rights of older people have looked to the World Health Organization (WHO) as a source of information and a source of leadership towards collective action. The WHO’s recently endorsed Decade of Healthy Ageing (2020-2030) (The Decade) is a concerted, multisectoral approach to improving the lives of older people through four action areas:
- Changing how we think, feel and act towards age and ageing
- Ensuring that communities foster the abilities of older people
- Delivering person-centred integrated care and primary health services responsive to older people
- Providing access to long-term care for older people who need it
Undeniably, the global response to COVID-19 has highlighted that much work needs to be done throughout The Decade. Through age-dependent triaging policies, the world has been witness to overwhelmingly negative feelings and actions towards ageing and older. Due to social distancing protocols, communities are fractured and unable to support the needs of older people. Person-centred integrated care and primary health services are largely on hold, as health systems are overwhelmed with managing COVID-19 case loads. Finally, and devastatingly, some long-term care facilities have become dangerous disease hubs rather than places of safety and security for vulnerable people.
Recognizing the urgent need for protecting the rights of older people in this critical time, the IFA has sought to better understand the attention given to the needs of older people in technical guidance provided to WHO Member States. The WHO Technical Guidance website provides tools and resources intended to equip Member States to appropriately prepare for and respond to the COVID-19 pandemic in a variety of settings and scenarios.
While it could be argued that many of the guidelines are for ‘all ages’, older people comprise nearly one billion people globally and experience disproportionately more severe social, health and community consequences of the COVID-19 pandemic compared to other population groups. IFA applauds the work of the WHO in producing the technical guidelines and resources (including publications, reporting forms, factsheets, online courses and guidance handbooks) to date which are informed by internationally respected experts. Within the 76 publications, 27 either note and / or address in broad terms issues pertaining to older people, and within these 8 provide detailed guidance on a specific topic such as long-term care facilities.
WHO Technical Guidance Regarding Older People
Overall, there are inconsistencies in how older people are referred to in the Guidelines, and the varying language (such as ‘vulnerable people’ or ‘the elderly’) will impact whether the specific needs of this vulnerable group are actioned within Member State plans. Without explicitly designed guidelines that address issues and scenarios faced by older people in all countries including those low- and middle-income nations there is real danger for interpretation and over-simplification. Several examples below highlight areas in which it may be useful to consider reviewing.
- Guidelines on national preparedness and responses such as the “Operational considerations for case management of COVID-19 in health facility and community” recognize that older people and those with comorbid conditions are populations at greatest risk of the consequences of COVID. Practical guidelines regarding public health interventions, community infection prevention and control (IPC) activities, and treatment referral pathways targeted to older people are sparse.
- The “Laboratory testing strategy recommendations for COVID-19” states that given limited resources, virus testing should be prioritized for people at-risk for severe disease, vulnerable populations, and those in institutions such as long-term living facilities or hospitals, but the language does not explicitly state the urgency of prioritizing older people.
- More significant consideration is afforded to older people in the contexts of case management in clinical, pre-hospital emergency and home care settings. In the “Clinical management of severe acute respiratory infection when COVID-19 is suspected” guidance there is a clear focus on the provision of person-centred health assessments which aim to understand the life, values, priorities and preferences for health management of older people. The “Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19)” guidance highlights that older persons and those with comorbid conditions require special attention and prioritization when it comes to ensuring appropriate care provisions.
- The “Recommendations: Prehospital Emergency Medical Services (EMS) COVID-19” guidelines outline issues of functional decline in older age that must be addressed in emergency situation. For example, motor impairments may prevent older people from using protective equipment such as masks, and hearing loss may require health providers to be in closer proximity to older adults to provide adequate services.
- The “Home care for patients with suspected novel coronavirus (nCoV) infection presenting with mild symptoms and management of contacts” guidelines recommend that Member States prioritize the needs of patients with the highest probability of poor outcomes, including patients with severe and critical illness and older people remaining at home. This includes making sure resources are available to patients and caregivers about personal hygiene and basic IPC measures to prevent the spread of COVID-19 and ensuring access to health care providers or public health personnel in case urgent concerns arise.
- The “IPC guidance for long-term care facilities in the context of COVID-19” is a crucial set of guidelines as it focuses on necessary precautions that long-term care facilities must take in order to protect their residents, employees, and visitors. Particularly in these settings, Member States with existing long-term care facility infrastructure must recognize the need to revise, or in some cases overhaul, existing living standards in order to rise to the recommended safety standards. Recommendations for physical distancing are essential to slowing the spread of COVID-19, but these are called into question in communal living facilities with bathrooms shared by over a dozen residents, for example.
- Considerable attention is given to the mental health impact of increased IPC protocols, isolation, and misinformation to an among older people. The “COVID-19: How to include marginalized and vulnerable people in risk communication and community engagement” handbook acknowledges that older people are among the most vulnerable to marginalization and COVID-19 fatality, and must be continuously engaged in decision-making processes for effective response, recovery, preparedness, and risk reduction.
- The “Practical considerations and recommendations for religious leaders and faith-based communities in the context of COVID-19” guidance recognizes the important role of community leaders in reinforcing “positive messages that affirm the dignity of all people, the need to protect and care of the vulnerable, and inspire hope and resilience in those affected by, or vulnerable to, COVID-19.”
A Call for Collective Action
The WHO Country and Technical Guidance – Coronavirus disease (COVID-19) technical guidance organised by topic is a dynamic set of evidence-based resources that respond to a global pandemic never before seen by citizens across generations and all levels of governments.
In this collection there appears to be a lack of guidance to cohesively connect interdisciplinary stakeholders around older people, which then results in a lack of ownership over responsibilities, and consequently a fragmented response. There remains a significant and concerning gap in addressing scenarios depicting the heterogeneity of older people and implications of socio-economic status through a gender and cultural lens.
For instance, guidelines do not appear to be available for Member States whose nations are currently experiencing the impact of natural and man-made disasters and the humanitarian implication separate to yet connected to the COVID-19 pandemic. The needs of older people in low- and middle-income settings such as migrant camps and slums, where IPC standards are vastly different from those in high-income countries are not well addressed. In addition, the impact of national lockdowns should also consider community dynamics including the potential for domestic violence and elder abuse and must assess the resources available to support individuals that are homeless and living in extreme poverty. Finally, although we may not yet be in the final stages of this pandemic, approaches to recovery and rehabilitation, return to work and/or community activities, and travel post-pandemic also require attention.
The International Federation on Ageing, being in formal relations with the World Health Organisation applauds the current technical guidelines and acknowledges the complex and rigorous process which is undertaken to produce these in a very short period. Principles outlined in each document provide a critical framework for adaptation in local situations bringing together collective action from local actors and influencers. While the WHO is a source of leadership by producing evidence-based reports and sharing best practices, the guidance points to a need for collective response to the issues affecting older people rather than mainstreaming which is largely the case.
Central to the WHO Technical Guidelines and Member State action must be the act of upholding the fundamental rights of every single human being to life and health—and to prevent the pandemic from spreading rapidly across the whole of society. As a society we cannot afford to leave anyone behind, especially those forced to leave their homes and communities.
Living ‘with’ COVID rather than post-COVID needs to be our mantra, to learn from errors, to celebrate the new collective actions across sectors and disciplines and to share the resilience and courage of older people and their families and those most vulnerable. The Decade of Healthy Ageing in its four action areas provides a framework of four action areas to consider in the multisectoral approach to improving the outcomes of older people, across generations going forward.