An Interview with André Picard

This transcript has been edited for clarity and length.

Ian MCKAY: André Picard has been renowned across Canada for three decades as one of this country’s most respected writers on health care. This year, André has brought out Neglected No More: The Urgent Need to Improve the Lives of Canada’s Elders in the Wake of a Pandemic.[1] I’ll be chatting with André for about the next 30 minutes or so about his book, and then he has graciously agreed to respond to questions from the audience.

Congratulations, André, on your thought-provoking book on a topic that has seized the attention of Canada since the start of this pandemic: the plight of people in eldercare. Neglected No More is in many respects a book from a journalist striving for objectivity. Yet, at the same time, it strikes many notes of moral outrage.

For example, you write: “There are times when I can barely contain my fury at the indignities that continue to be endured by elders.” Of your own parents’ experiences, you remark, “Their care was frustratingly difficult to access, disjointed, costly and, ultimately, mediocre at best. In other words, typical.” You write: “In Canadian healthcare, it seems, no screw-up, no matter how big or small, how sickening or deadly, is ever anyone’s fault. It’s always the fault of ‘the system.’ So let’s fix the damn system.”[2] How challenging have you found it to balance the journalist’s pursuit of the factual, with a campaigner’s quest for better health care?

André PICARD: I don’t think it’s too difficult to balance. If you look at the facts about this sector, you can’t but be outraged. There’s just no question that it’s failing on many, many levels. I think you can present the facts and the anger follows, almost naturally.

What I try to be is not objective – but fair. I [tell] a lot of stories of families etc. in the book. There’s a lot of stuff to be angry about there, but I think it’s ultimately a hopeful book, because what I try to present in it is a summary of stuff that needs to be done, what we know is wrong, what we know how to fix. The uplifting thing is we do know all the problems and we do know all the solutions. This has been studied to death. It doesn’t take a lot of effort to fix things.

MCKAY: At the same time, the phrase you use was “nihilism.” Did you really sense that kind of nihilism around the pursuit of herd human immunity without a vaccination?

PICARD: When I think of nihilism, I think of how we treat the idea of aging. We catastrophize it:  “Oh, no, we’re getting old!” To me, I hate such terms as “grey tsunami” (for example), because to me what’s happened to our demographics since the Second World War is a miracle of science. We’ve had advances in life expectancy that are unprecedented in the history of the world, in a very short period. That’s something we should be celebrating. We shouldn’t be pulling our hair out… The fastest-growing demographic in the country are the centenarians. I don’t know that why that should make us alarmed – quite the contrary. I have the privilege in my work of talking to lots of older people in their 90s and 100s… It’s a gift. They’re living history.

We have to remember that the vast majority of people who are over 100 [years old] are still living in the community, and they’re healthy… The vast majority of people stay well until the very end. There’s a very small percentage of people who need chronic care. We have to take good care of them. I think we make the mistake of thinking that’s the reality for everyone, and it’s not.

MCKAY: You argue that Canada’s almost flipped the priorities that you find in a place like Denmark, where the vast majority of people have home care or [exercise] another non-institutional option, whereas we went whole hog with institutions… You suggest that maybe as many as half of the people in long-term care don’t actually [belong] there.

PICARD: We’re very much prisoners of our history… Why do we do a lot of things? Just because we’ve always done them that way. We have a very hospital-centric health care system.

Everybody loves Medicare, but I often make the point that we have the least universal health care system in the world. We brought in universal care around the same time as many countries, like Britain and many European countries, but they kept changing and we didn’t. We’re stuck in 1957, with a system built for people in the 1950s. That’s not what the world is anymore.

It’s about adaptation. When we look to other countries, it’s a reminder that this can be done easily. It’s not going to bankrupt us. There’s this constant argument: “Well, we’d like to treat our elders better, but it’s too expensive.” It’s not true. The countries with the best eldercare actually have much cheaper health care costs than Canada, because they take better care of people.

MCKAY: You say there is no overarching system. No one is in charge.  We think that we’ll be safe as Canadians when we get older, and we think our costs as seniors will be covered – but you document case after case in your book of people who thought they were okay and then, confronted the healthcare costs of caring for their declining parents, they are facing acute financial hardship. So, would it be fair to conclude from your book that eldercare in Canada should be rendered both systematic and affordable?

PICARD: This reminds us of the Mythology of Medicare: this notion that we think we’re going to be taken care of no matter what happens to us. We know that’s not true. We know that Medicare really funds 100% of hospital care and physician care – but with the rest of the system, you’re often on your own.

You pay a little less than half of drug costs, about 40 percent of long-term care and home care costs. That’s a lot of costs that suddenly you’re hit with. Usually, you’re older, you’re retired and you don’t have a lot of disposable income. It comes to a big shock – people are not expecting this. They don’t plan for it. So, we really have to make some services more universal, but we also have to be really clear about what’s covered by our government programs, and what’s not.

These things shouldn’t be surprises. We should be able to plan for them. We do very little planning…

The average Canadian at retirement has something like $4,000 in savings. That’s about the cost of one month in a long-term care home. We’re just not prepared for this in any way, shape, or form… So many bad things happen because people are just shocked. There’s a crisis and then they get tossed into this non-system. It’s like falling down this rabbit hole with a not-very-good landing. It’s a very frightening experience for many, many families.

MCKAY: I find fascinating the paradox that it’s both a “non-system” and intensely bureaucratized. Workers within the system say that they spend almost half their time just filling out forms and responding to questionnaires and annotating checklists. It really interferes with how much time the patients in LTCs receive.

PICARD: It is very bureaucratic – our health system in general – and I think eldercare is even more so, because it’s not centrally funded,  so that brings in a lot more paperwork. One third of all home-care dollars go into… figuring out if people should receive home care. Essentially, we spend one in three dollars trying to figure out how not to not spend more to care for people. There’s an absurdity that built in there that we don’t address.

MCKAY: When McMaster’s Mat Savelli, in our Department of Health, Aging and Society commented on the Canadian Armed Forces’ report about long-term care homes (which documented starved, filthy, drugged-out, sometimes abused old people),  he remarked that he had been “hit by a crush of emotions: anger, disgust, fear, and sorrow.” Yet, “there was one emotion that was totally absent from my response… surprise.”[3] Was that your reaction as well?

PICARD: Oh, very much. I know all of this; I’ve known it. I’ve seen this same report a thousand times.

What was really interesting was that, because someone different was saying it – it’s the military; we have great respect for the military, they said stuff in plain language  – and people were shocked. I remember a lot of nurses contacting me, being puzzled, saying: “We’ve said this a thousand times – why is someone finally listening?” …It’s another one of those curiosities of daily life –  we pay more attention to something just because it’s coming from a different source…. The military report came from a different place… There was nothing new in there, but there was lots that was shocking. The day-to-day reality is, in fact, shocking.  

MCKAY: Back in the Spring [2020], when you were writing about this in The Globe and Mail, you actually advised people to get their elderly relatives out of long-term care as fast as they could. You had a sense in April that it was really a disaster about to happen.  

PICARD: Yeah, I think anyone who had the least bit of knowledge about the system knew that big trouble was coming. This was entirely predictable. To me, that’s the biggest frustration about the death rate… I’m not an expert by any stretch of the imagination, but I just saw what was going on in Italy, what was going on in Spain. We knew exactly what was going to come to Canada. We knew we had even worse conditions than they do in their homes. We knew what was coming, and we did nothing to protect people. That to me is the most inexcusable thing.

We hear, for example, the Premier of Ontario saying repeatedly: “Oh I’m going to have an iron ring around these homes.” Well, there wasn’t even a papier-mâché ring. There was nothing. They were left to their own devices.

This is a structural problem. Our health system is built around hospitals. Hospitals were incredibly well protected. Our hospitals did exceptionally well during Covid. They have all the money, they have the resources. That just makes the other failings of the other part of the system all the more blatant. We left them [LTCs] when Covid was spreading at a rapid rate – just a forest fire of infections… We didn’t even have personal protective equipment for workers. They were in there with nothing, not even a paper mask.

The deaths [that] occurred between March 22 and April 22 of 2020 were very concentrated. It was a massacre of huge proportions. There were many homes where half the residents died within a week… I don’t think people have a real sense of just how horrific things were, and that’s unfortunate. I think if we had seen the full breadth of the horror earlier on, there would have been more of a reaction, and we wouldn’t have had a second wave, which was even worse. This was even more head-scratching. How could we have not learned from experience?  

MCKAY: In clearing out the hospitals, to protect them from Covid-19, the authorities sent many people to long-term care homes, and the disease just spread that way.  

PICARD: Another example of how wrong-headed approaches to this were. Many people live in hospitals. This is a dirty little secret of Canadian healthcare. (We have a term for this: “alternate level of care,” i.e., “no care.”) There are about 7,500 people who live in hospitals… because there’s nowhere else for them to go. Almost all of them have advanced dementia. They just live in these hospitals. But when Covid came along, we wanted to protect our hospitals. So we shipped them off to nursing homes, where we were told there was no room. Many of them died as a result. They wouldn’t have died if they had stayed in hospitals, even though they shouldn’t have been there in the first place.

Another example of wrong-headed policy: we essentially shut down home care in Canada during the pandemic. We shut it down at a time when we were telling people the safest place to be is at home. “Stay at home, stay at home!” was the message. But then we told elders, “Sorry,  we can’t help you out. You have to stay in an institution…”

MCKAY: Drawing on Australia, you discern a real move from a ration-driven to a rights-based approach to eldercare… You also draw on Denmark, which has a much more holistic and less institutional approach than ours… I think you’re arguing for a paradigm shift, away from a ration-based system. In a way, it’s reminiscent of Tommy Douglas and the social democrats in Saskatchewan in the 1940s, who came up with hospital insurance, and then Medicare in the 1960s. Don’t people who really want that change to happen need to prepare for the enormous pushback from people who have a strong vested interest in their property rights in healthcare – such as the professionals and the profit-seekers who blocked Douglas’s vision of eldercare in the 1970s? “That’s too expensive, we can’t do that, it would make people lazy.” Aren’t those people still up and running today? Aren’t they going to make exactly the same case?

PICARD: I think to a certain extent, yes. But, I don’t think the challenge today is anywhere near what it was at the time of the introduction of Medicare. The insurance companies really ran the show back then; they dominated. It’s very different now… We already have a lot of government in that sector.

To be honest, a lot of these companies don’t want to be in the business of care. They want to be in the business of real estate, and that’s fine. But what we have to [do]… is make that distinction clear.

There was a long-term care commission [that] reported in Ontario just a few weeks ago now. They had really excellent recommendations about that. We have to make this distinct separation of ownership versus care delivery. And there’s no question that care delivery should be done by not-for-profits.

We don’t have profit in care in Canada – but we have profit in the housing part. And in long-term care, it’s all kind of intermingled in this really icky way (if I can use a very technical term). It’s just a mess. So, we have people who are essentially “slum landlords.” These people want to own the land and they want to make money off rent – which is fine, they can do that in society – but then they’re forced by the system to also provide care. They don’t want to. So, they do the bare minimum.

Let them own the real estate. Let them collect the rent. But then, let’s make sure that the care is delivered by people who know how to deliver care.

I think there’s a long debate… about getting profit out of care, and to me that’s important. But it’s not the biggest priority. I don’t think ownership is a panacea. I think it’s important. But I think what’s more important is to make sure that the care is provided by care companies or institutions, and that the real estate part of it be broken off. I think that’s a really important distinction to make.

MCKAY: These ideas about treating people as customers and treating care as a commodity are to be found pretty much throughout the whole system. Much of it is driven by new algorithms and programs that tell people, “this is what efficient care really means. This is how long you should spend with patients.” It, in other words, seems to me a neoliberal approach. I notice the word “neoliberal” doesn’t once come up in your book, I don’t believe…

If we’re going to go to your more humanistic, caring approach, don’t we actually have to dissolve these neoliberal habits of mind, these neoliberal practices, these neoliberal structures that really give people permission to treat other people like their things?

PICARD: There’s no question. I don’t use the term “neoliberalism,” but I use the terminology that we have to deliver patient-centred care rather than treat people like widgets. That’s how we do treat them. Our health care system or the long-term care system is task-oriented; it’s not person-oriented.

The Norways, the Netherlands, the Denmarks of this world all have algorithms and stuff, and that’s fine, but they let the people take control. I visited a long-term care home in Ontario, before the pandemic. They had 91 pages of regulations that they had to follow… Lots of check marks. Not one of those 91 pages asks the questions: “Is the person happy? Are they well cared for? Do they like it?”

We don’t ask the important questions. We ask, “Is the temperature of the butter in the fridge proper, so they won’t get food poisoning?” That’s important, but it’s not as important as, “Are you happy? Are you sad? Do you have friends?”

By contrast, when I go to a care home in Denmark, and I’ve done this, and ask, “Well, where is your list of regulations?,” they just laugh. They say, “Why do we need regulations? The rule is, our staff is here to take care of people. You provide the care that they need to be well to be happy, to have good quality of life. You can’t spell that out. Some days it means giving people a bath, some days it means having tea with them, sometimes it means doing things that they don’t want done, but you have to do. You have to know the person. You must have a relationship.” That’s the difference that I want to see. And you can call that getting rid of neoliberalism. I just call it having more patient-centred care or family-centred care.

MCKAY: Is that really compatible with corporate ownership?

PICARD: I don’t think it’s totally incompatible. I think we, companies, whatever, will provide whatever the customer wants. (If you want to use that customer language – I’m not big on it, I prefer the patient or resident – but the customer language is not always bad.) A lot of private corporations deliver good care (in many cases, better care than public institutions), because they don’t have the checklist. They say, “Listen, we charge you a lot of money and we’re going to provide you with good care. You’re paying $15,000 a month. I’m going to make you happy.” That’s not all bad.

MCKAY: It’s great if you’ve got the financial resources to do it, right?

PICARD: But that’s my point. There’s no reason we can’t do that, or most of it, for everyone. It doesn’t have to cost that much.  

MCKAY: You soberly add up all the reports, going back at least six decades, calling for the overhaul of eldercare, and you’ve expressed real impatience with the whole business of reports. The idea of another report just gathering dust on the shelves doesn’t make you smile.

I still wonder, given the complexity of our “non-system,”  i.e., that we can’t even say how many PSWs are working coast-to-coast (maybe 400,000, maybe 300,000) – even some basic facts are not there, and we have 14 political jurisdictions (not counting the municipalities) to consider – [whether some new investigation is not required]. This is a phenomenally heterogeneous and complicated non-system. I personally don’t see a way of coming up with a holistic, systematic, enforceable new philosophy without some kind of founding investigation. Maybe a Royal Commission? Would you accept a nomination to serve on it?

PICARD: Well, I could certainly rule that out. I think there’s a place for reports, but some of the things you mentioned (for example, like how many PSWs are there?) – we don’t need a Royal Commission for that. We just need to sit some people down in a room and figure out our data, [and] how we can make our data interchangeable between provinces. A lot of this stuff just needs to be done. It doesn’t need a big public spectacle.

The problem I have with big reports is that they allow governments to cherry-pick and to just do the stuff that’s easy. They get a little bit of bang and the press off their backs.

I’m a health journalist. I get 100 reports a week. My frustration with reports is that most of them are never acted on… I don’t want to read a report that doesn’t have recommendations that are fully-costed and doesn’t have a timetable. Most reports don’t… Reports should be commissioned to solve very specific problems. I don’t want a report that says, “Tell me how to fix elder care,”  because I know. What I want is really specific.

Take an example of a hot political topic: standards in long-term care. I would want a report from the government saying, “I have a billion dollars to fix this issue that you tell me is a problem – long-term care standards. Tell me what to do tomorrow with a billion dollars. Tell me the timetable. And I’ll do it.” You have to commit to do things up-front. If governments don’t commit to do things when they appoint a task force or a commission, I think it’s going to be 90% hot air. You have to commit up front. I know that’s risky politically, but… it would really focus the mind. Governments would say, ‘Okay, this is something I’m going to fix today. I have the budget for it and I’m going to do it” –  rather than all this pie-in-the-sky. I acknowledge a lot of stuff is not to going be fixed overnight, and that’s fine. So, pick your spots, and do it. Commit to it and actually do it – not just talk about it.  

MCKAY: I wanted to ask just one more question: about bringing people to justice. I was thinking, as I’ve been reading some of this stuff, that if I had done that to my dogs, I would be answerable to a court of law. If the farmer neglects his livestock and they all die in a barn, that farmer has to explain why it happened. If that farmer’s been negligent, that farmer should have to answer for it. Do you think that there’s a case for prosecutions against some of these proprietors of care homes?  

PICARD: I think there is, maybe, in some very rare cases. But the reality [in such cases] is… nobody ever goes to jail. That’s the reality in Canada. Our laws don’t really lend themselves to it. The reality, too, is nobody is responsible. It’s hard to blame someone. There’s no responsibility in our system. There’s no accountability. I’m not sure you can impose accountability retrospectively.

I’m not big on finding scapegoats, etc. I’m not sure that’ll solve anything. I’m really big on being forward-looking. Let’s figure out how to do this, so it doesn’t happen again.

There are already some civil suits underway. Those tend to bring about more change than anything else. [Consider the tainted-blood issue of the 1980s and 1990s]. That resulted in five billion dollars in penalties. That brought about change. Five billion dollars is going to make people sit up and pay attention and do things differently. Our blood system, our health care system overall, is dramatically better because of that, and that’s good.

These legal proceedings, whether they’re civil or criminal, will bring about some change. Putting people in jail? I can’t see it happening, and I’m not sure that it’s necessary or appropriate.

I hate when people say it’s all the fault of the system, but the fact is, it is the fault of the system. There’s no responsibility. It’s very diffused. So we… have to fix the damn system rather than try and put a couple of people in jail. That’s not going to solve anything.

QUESTION FROM THE AUDIENCE: Picking up on your comments about having a billion dollars: if I had a billion dollars to give to you, what would you do first?

PICARD: Specifically in eldercare?… I think you have to start where the biggest problem is, and the biggest problem is staffing. I think, to me, everything in healthcare begins and ends with people. Healthcare is about people, caring for people.

We have a really fundamental human resources problem across the board in Canadian healthcare. Vast shortages of nurses, etc. And it’s even worse in eldercare. So, I would start with a long-term care standard that ensures four hours of care daily ­hands-on care for everyone – in institutional care and home care ­– and that would be an average because some individuals need more this four-hour average. To me, that’s where you start.

We know how much that costs. It’s been costed by people like Pat Armstrong, almost down to the penny. We know, for example, that would it cost 1.8 billion dollars in Ontario. To its credit, [Ontario] has committed to do that but only in 2025… I would start, in making sure that people have the hands-on care.

Again, this flows from Covid. The most horrible thing about Covid [even more than the thousands of deaths in LTCs] is how people died. They died alone. They died wallowing in their faeces. They died without palliative care. We have people in Canada in 2020 who died of starvation and dehydration, just because there weren’t people there to give them a glass of water. That to me is the most barbaric thing that’s ever happened in Canadian healthcare.

So that’s where you have to start. Make sure that people are there, to care for the most vulnerable group in society – frail elders in institutional care.

MCKAY: I would go back to the neoliberal work world – the pressure to get people to work harder, to work without security, to rely on people in the gig economy, as we did in 2021 in care homes… without job security, often racialized women whose second language is English. In other words, don’t we have to go back to the hard core of the political economy of healthcare and say, “Okay, why is this staffing crisis upon us?” Surely, it’s this pressure to rely on flexible workforces and just-in-time delivery, with no slack in the system. There are neoliberal themes here that I thought could be emphasized a bit more.

PICARD: There’s a famous saying by Pat Armstrong: “The conditions of work are the conditions of care.” If we treat workers well, our elders are going to be better treated. Again, we see that from the Nordic countries. The workers are treated well and the care is excellent. There’s no secret there. That’s a magic formula.

Covid was the intersection of ageism and sexism and racism. It was racialized women caring for older women, who are just tossed to the margins of society.

We’ve seen personal support workers come to the fore. We’ve seen them for the first time ever. They were these invisible people before Covid. I think people have come to appreciate them much, much more. That’s a start. Exposing their work conditions is one thing; fixing them is another.

QUESTION FROM THE AUDIENCE: A lot of people are neglecting to notice is the race and gender factor with care workers, especially women PSWs. I think a lot of people also forget that they have children as well, who are now doing remote learning. Who’s going to take care of them? You can’t really leave them with your mom or dad to take care of, and day cares are closed…  It’s really almost kind of hurtful to these care workers who do try their very best. First-hand, I’ve experienced the love and support they do give to residents. Care workers feel a little bit embarrassed and upset that this is the name they’ve been given, currently.  

PICARD: I always try to stress that there is a lot of good care. It happens in spite of the system, not because of it. That’s why I’m kind of an obsessive about fixing systems. We have to make it easier to care.

I’ve met many, many caregivers, PSWs – a lot of them Filipino women and Québec-Haitian women – and they’re exceptionally dedicated. They do incredible work. I hate it when I see the term “unskilled labour” [applied to them] because it’s very skilled work. It’s low-paid labour is what it is. It’s underpaid and undervalued.  

I was struck when I was doing interviews for the book how a lot of people I talked to didn’t complain about their wages (even though they’re horrific). They just said: “What breaks my heart is, I don’t have time to care, I don’t have the time to sit and talk to people.” They do incredible work. We have to be careful (and especially in the media) not to throw out the baby with the bath water.

In places like Quebec, PSWs were getting paid as little as $13 an hour. The government has doubled their wages; they’ve hired 10,000 new people. That’s a start… We have to give more recognition to this group and more appreciation. Some of that has come through Covid. It should not have taken a pandemic.

The first chapter in my book is about what happened at a home called Heron in Montreal, where the police went in, and everybody had been abandoned. Almost all the staff had left – there were only three people left, and they were low-paid PSWs. And a lot of people blamed them: “Oh, how dare they! The older people were dying! How dare they flee!” I [reflected], “Who would put their life at risk for $13 an hour (and they did it for weeks and weeks, and never got any help)?  Of course they quit.” They were falling sick with Covid, they had their children at home, they’re putting a lot of people [at risk] who live in multi-generational homes. We can only expect so much of people to sacrifice. I think we have to be careful to give that context to the public.

QUESTION FROM THE AUDIENCE: Obviously the biggest actor in fixing the system is going to be the government. How much of this responsibility falls on the people of Canada as a whole to push the government to make this change? How can we, as people who are aware of this issue, make those who might not be as aware, more cognizant of it?

PICARD: I think there is some personal responsibility there. Some collective responsibility. I’ve been at this for a long time. When I was younger, I was much more critical of politicians, to be honest. I’ve recognized over time that politicians essentially lead from behind.  They will do essentially what they think the public will tolerate.

One of the biggest problems in this sector: we’ve been too accepting of [the notion that], “Well, they’re kind of old, they’re going to die anyhow, so we can’t afford it.” We have all kinds of excuses.  I think a lot of it is this denial. We all live in denial that we’re going to get old and maybe frail and need some help, someday.

I say in the book that, to me, the most important conversations for changing the system have to happen at the kitchen table. They have to be people [asking]: “What’s going to happen if I need this care? What am I going to get? What do I expect?” And people are going to realize, really quickly, you’re not going to get anything near what you expect. That’s how we’re going to bring about change – when we demand it and insist on it.

I think everybody loves their mother and their grandmother and they want them to be well cared for. I think we have good values as Canadians. We just have to take that individual belief and apply it collectively. We should think nobody’s grandmother should be treated any worse than mine…. It’s important sometimes to put it in those emotional, practical terms for people. “Listen, how do you want to live out your life?” I don’t think people want to live out what they’re seeing in long-term care homes.

One of the most uplifting things for me is… the number of younger people who are interested in this issue. Once you have agreement that something is important across different demographic groups, that’s when change happens really quickly. If 30-year-olds and 50-year-olds and 90-year-olds are all demanding the same thing, governments [are] going to do it, because otherwise they’re going to be in big trouble.

We do have a big personal responsibility to speak out about this. And not only speak out about it – but actually make it matter at the ballot box. I’d like us to make health care a priority when we go to the next election.

QUESTION FROM THE AUDIENCE: What do you think it would take to shift the system towards supporting home care for more people. Do you think that would be a good thing?

PICARD: Well, I think… there’s no question that we have to spend more efficiently, if I can use some neoliberal language. I think we have to be smarter about the spending. So, economically it makes sense to have more home care. I think we have to respect people’s choice. We don’t like to use the “c-word” in health care; it’s almost a dirty word to say people should have choice about how they’re cared for.

There was a poll out recently saying 95% of Canadians said they never wanted to be in long-term care. Some people said they’d rather die than be in long-term care (I think that’s a bit much personally – there is a lot of good care out there). People do want to stay at home. To me, that should be the default position. The default position should be, like in Denmark, for example. “We’re going to do everything in our power to keep you in the community because we value you and that’s where you want to be. So that’s where we’re going to spend first and foremost. We use facilities or institutions as a last resort. They’re definitely necessary and essential – but they have to be the second choice, and not the first.”

In Canada right now, the default setting is, when anything goes wrong, off to the institution! We’ve lost this whole middle ground between being healthy and being institutionalized. We don’t spend enough on supportive housing or home care.

In Canada we spend 80% of our eldercare dollars on institutional care, 20% on home care. The countries with better care do exactly the opposite. Look at Denmark: 80% of money goes to home care, 20% to [institutional] care. And they don’t spend tremendously more. They just spend it differently and better and smarter.

QUESTION FROM THE AUDIENCE: What have you found most disturbing about the public discourse during Covid-19 regarding older adults?

PICARD: The most disturbing thing is just the inherent ageism that exists. Every day, I was writing a lot… in early 2020 about the horrors of long-term care. Every day I’d get bombarded by emails saying: “Ah, they’re old. They were going to die anyhow.” That’s the ultimate nihilism to me.

And, first of all, it’s not true of all the people who died prematurely. They weren’t [fated] to die. One hundred people were not going to die in a home care institution of 200 [people] in March, 2020. Four of them [in normal times] were going to die. That’s the reality. So this is nonsense.

Second, when have we ever accepted that people are disposable? Why is it okay that they die, just because they happen to be a certain age? I often use the analogy… of day care centers. I really think people would be probably on Parliament Hill with pitchforks and torches and ready to burn it down, [if they were told,] “Well, we brought 20 kids into the daycare yesterday, and 10 of them are dead. Oh, well, they were going to die eventually, anyhow.”

That’s exactly what we say about elders. It’s not acceptable. That, to me, is the disturbing part. We do have this ingrained ageism in all of our public policies. I called it “elder apartheid” in the book. I think that’s really what it is. We take people, and we remove them from society, we strip them of their citizenship. That’s what we do when we put them into institutions. That to me is the disturbing part.

QUESTION FROM THE AUDIENCE: Why is dental care not provided very often in long-term care homes?

PICARD: Well, I think the broader question is why, in our Medicare system, the mouth not [considered] part of the rest of our body? It’s a fundamental flaw of Medicare. Many universal health care systems cover dental care as much as other as hospital care.

Why don’t we provide more care in these institutions? Why do a lot of elders have this revolving door, in and out of the emergency room? When anything even mildly goes wrong, off they go in an ambulance to a hospital. It’s very off-putting if you’re 90 years old and you’re getting shipped around. It’s not easy. In many cases, it exacerbates people’s health conditions. I think whether it’s dental care, whether it’s provision of antibiotics, or whatever, we should be doing a lot more in these homes.

Now that being said, I don’t want people to live in hospitals. Homes should not be hospitals, they should be homes. They should live in homes. Once again I point to Denmark. There the long-term care homes are actually homes. They’re not these prison-like facilities with 200 beds. They have around a dozen rooms (20 maximum).

MCKAY: You point out that the Canadian penchant is for building big institutions with narrow corridors. You call them “horridors.”  

PICARD: I didn’t coin the term, but I did use it, I think it’s a great term for these really long narrow hallways that we only see in hospitals and in horror movies.

One of the things that was the most fun for me about doing the book was talking about the history. The whole history of long-term care institutions came up through the penal system. It really has nothing to do with health care. It has everything to do with crime and punishment. Until very recently (and maybe in some people’s minds today) being poor is… a crime. When people were indigent and older, we put them in these homes. They had to work for their gruel, often quite literally. (That goes back to the Elizabethan Poor Laws; we imported this into Canada with the British system and to a lesser extent with the French system, which was based more on the church model but… was no less grim, if I could put it that way).  People are still shocked when I tell them that, until the 1960s in Canada, we still had homes that were treated like penal institutions. The residents wore uniforms. They could be punished for not doing their chores – they’d be denied their meals, etc. They were put in ward rooms, 20 to a room, like a prison.  There was a big report written in Ontario in 1961… It [revealed] people who were in their 70s (which was old in the 60s) still locked in the basement, because they hadn’t done their chores. This is in my lifetime – and I’m not that old.  

QUESTION FROM THE AUDIENCE:  What changes do you think are necessary in our current home care infrastructure and economy, to make the sort of Denmarkesque/Nordic model that you’re referencing possible?

André PICARD: The overarching thing for me, for changing eldercare overall, is philosophy. I love the philosophy in Denmark: “We value you, therefore we want you to live among us.” Once you have that attitude, everything else is really plumbing. So, to me that’s the key.

Then there’s a lot of practical stuff that flows from that. We can’t have this hierarchy of pay. We have a hierarchy in Canada. Say you’re a personal support worker. You do the exact same work [as other PSWs]. You get paid well in the hospital, you get paid less well in a long-term care home, and you get paid abysmally in home care.

Well, surprise, surprise! It’s hard to get home care workers, right? So there has to be parity of pay. That would solve some practical issues with human resources.

I think we have to decide how to use home care. Right now, it is really just an extension of hospital care. It’s a way of freeing up beds for hospitals and giving people short-term bailouts. That’s what home care is in Canada. It’s not really designed to allow people to live in the community. Maybe we need a new name, even a new kind of home-care, based on living in the community for a long time period.

There’s a maximum of three hours a day [of personal attention] in home care. Some people need a lot more than that. So, why do they automatically go to institutions, where it’s going to cost way, way more money, and it’s going to be more unpleasant? We take them out of their suburban home and then we make them pay $2,000 in rent for a place they don’t want to live in. There are a lot of absurdities about that.

We have to get out from these artificial barriers. “The right care in the right place at the right time” has to be the philosophy. If you do that, I think, almost overnight, we could get rid of maybe 20% or 30% of institutional care. In Great Britain, they have a rule. They fund institutional care, they fund home care, but you can’t be unlimited.

Realistically, we can’t provide 24-hour-a-day home care. How do you set a limit? Well, a very basic starting point is do like in Britain. You can spend the equivalent of institutional care at home (in Ontario it’s approximately $200 a day for institutional care that the state pays). If you gave everyone the option of spending that on home care, you could get a lot of people out of institutional care tomorrow, with not a penny more spent.

So, a whole series of little things – but it all starts with the philosophy that people matter. I really think we should see people with dementia every single day of our lives. There’s a lot of them. We shouldn’t hide them away. We should adapt society to them. We should say, this is what the reality of living [entails]. We’re going to make a life as pleasant for these people as we can, until their dying day.

QUESTION FROM THE AUDIENCE: Is culture an important mechanism involved in developing intergenerational support and solidarity? We all have an interest in each other’s well-being. It’s hard to develop that if you never see these people, or you don’t have really any grasp of what’s happening until a crisis happens, and then, it’s all shock and horror.

PICARD: I think culture is really important – and I’m always cautious. I always talk about Denmark, I’m always talking it up, but I always say we have to adapt their philosophy. We can’t adopt their system because health systems have a lot of embedded culture [involved in them]. Canadians think differently. Our system is built differently. You can’t just transpose; it’s not going to work. But, you can take their ideas and adapt them to our culture.

The other thing I’ll say about culture: there are a lot of groups in Canadian society with multi-generational homes. Take the Chinese community. They don’t like sending elders away to care; you have an obligation to care for your elders, it’s built-in respect, etc. That stuff is all true. But we have to realize, too, that the culture has changed. There are long-term care homes for the Chinese community. Why? Because they don’t live all in the same home anymore. Maybe their kids live in Vancouver [and] they live in Toronto.

So we can’t just say, “Well, some groups don’t need care because they take care of their own.” That’s not true. The world is changing, cultures are changing, and we have to adapt.

There are some tremendous homes, for example, that provide care where everyone speaks Mandarin or Serbian, or whatever. That’s important, especially with patients with dementia. A lot of people revert to their first language as they lose their cognitive abilities. They lose their second and third languages. There are a lot of practical things that we can do here to make life easier and make the quality of life better for people.

MCKAY: Thank you so much for being part of this, and congratulations again on your book, a great contribution to the debate.

PICARD: Thank you very much, and thanks for asking the tough questions.

[André Picard spoke to Syndemic on 3 June 2021].

[1] André Picard, Neglected No More: The Urgent Need to Improve the Lives of Canada’s Elders in the Wake of a Pandemic (Toronto: Random House Canada, 2021).

[2] Neglected No More, 182, 181, 3.

[3] Mat Savelli, “‘Creating efficiencies,’ sacrificing human dignity,” Hamilton Spectator, 1 June 2020;