In the 1970s, when Quebec’s public nursing-home system was in its early heyday, it was said that parking lots cleared out in winter as healthier residents headed off to Florida.
Experts today aren’t sure how many snowbirds headed south from Quebec long-term-care homes 50 years ago, but the story remains a symbol of the long decline, both in resident health and quality of care, in the province’s LTC facilities, known in Quebec as Centres d’hébergement de soins de longue durée (CHSLD).
Quebec’s long-term care system grew from scratch at the tail end of a golden era around Expo 67 and the 1976 Olympics, when no project was too ambitious. By the end of the 1970s, the system had 60,000 beds and cared for seniors with a wide range of needs at a high quality of life. They were considered a retirement plum for Quebec’s elders.
Decades later, even before COVID-19 killed 1,674 CHSLD residents, often left lying in filth and suffering from dehydration, the facilities are reserved for the most infirm who get only very basic care, if things go well, as they await death. They are now symbols of warehousing and neglect.
In recent years, debates have raged over whether residents could have one bath a week or two, and whether they should have powdered potatoes, instead of real ones, to save a few cents a meal. The system has 38,000 beds, many of them crammed two to a room in crumbling buildings. The province today has two-thirds of the nursing-home beds of the 1970s, despite Quebec having three times as many senior citizens. The average stay before death is 18 months.
Jean-Pierre Lavoie, a social gerontologist and now-retired researcher, heard the 1970s Florida snowbird story many years ago while working on a research paper. “People in those homes often had few incapacities. The homes were expansive and well-funded. People were well-lodged, well-fed, even entertained. They were independent,” Dr. Lavoie said. “It was seen as a kind of reward for a lifetime of service.
“Now, it’s so traumatic when people put their loved ones in CHSLDs, they feel shame. People have often told me that bringing a parent to the CHSLD was their real mourning, more than death. It’s a trauma that lives on for years. That’s how far it has fallen.”
After the Second World War, Quebec had two main systems for elder care, a francophone system run by the Roman Catholic Church and a system for English-speaking Quebeckers run by charities. Both systems were small and mostly reserved for people with no family, or with health conditions that made living at home impossible. The church expected women to care for elders at home.
Like many of Quebec’s modern institutions, the government launched a long-term care system after the Quiet Revolution that saw the expansion of public programs. The influence of the church declined, women went to work and elders went to homes.
Michèle Charpentier worked in the homes in the 1970s, launching a career as one of the province’s pre-eminent elder-care experts. They were called “retirement welcome and accommodation centres” and Dr. Charpentier remembers painting classes and personal-growth workshops.
“I think it’s a bit of a caricature that they would empty in the winter, but the homes did have big parking lots because so many residents still drove,” said Dr. Charpentier, who is now the research chair in aging at the Université du Québec à Montréal (UQAM). “Nobody who goes into a CHSLD now drives. Most have dementia. It’s another world.”
The system of the 1970s, however, ran contrary to a growing de-institutionalization movement. One study suggested that half of the seniors living in Quebec nursing homes could have been on their own. “There were unintended consequences,” Dr. Charpentier said. “We were institutionalizing people who didn’t need it.”
Governments shifted away from institutional care, promising a vast expansion of home care. Then, economic turmoil of the late 1970s and 1980s triggered financial constraint. Even in good times, home-care promises have gone undelivered, according to Nancy Guberman, a retired UQAM professor. “The rhetoric has always been there. The money never followed,” she said.
Meanwhile, with plunging birth rates, Quebec society aged faster than any other province and almost any jurisdiction in the world, Dr. Charpentier said.
Newspaper exposés on neglect became their own industry. A 2000 Journal de Québec headline summed up the plight of a CHSLD resident this way: Deux ans sans un bain. “Two years without one bath.”
La Presse reporter André Noël won Canada’s highest journalism prize, the Michener Award, in 2004 for exposing that at least 400 Quebec seniors had died from neglect in CHSLDs since the 1990s. These deaths came from falls, malnutrition, medication errors, suicide and murder. Dehydration and sitting for hours in soiled diapers were routine, he wrote, echoing current reports about CHSLDs.
Over 20 years, coroners’ reports, public inquiries and government committees studied the system. Premiers and ministers of every political stripe vowed to change it.
“We’re putting a magnifying glass on it again now, but I’ve been testifying for decades about what was going on in these institutions,” Dr. Charpentier said. “When a system is holding on by a thread, this is what happens.”
Outside the CHSLDs, a few things changed. A massive private industry in seniors residences grew, with some moving into heavier forms of care provided by CHSLDs. Dr. Guberman said the private homes became a political crutch for neglecting CHSLDs.
Over the past two decades, bureaucratic changes put multibillion-dollar hospitals under the same centralized administration as tiny care homes.
“Senior care is a drop in the bucket, a poor cousin of the health system,” Dr. Guberman said. “It gets no attention. It’s where old people go to die. It’s the last thing they worry about as they look at hospitals and technology and ER overcrowding.”
Dr. Lavoie added that when the pandemic crisis hit, the system had no flexibility to adapt. “They created bureaucratic monsters and now we’re seeing it. In a crisis, when acting quickly is key, hyper-centralization and having thousands of employees under one umbrella has left small institutions unable to react,” he said.
In the past five years, Quebec’s finances improved massively but investment in seniors’ care came too late to help with the pandemic.
In the budget unveiled in Quebec City in early March, Premier François Legault dedicated an additional $380-million for home care, bringing the budget to $1.9-billion, and $2.6-billion to build new long-term care homes to be redubbed “les Maisons des ainés.” (Mr. Legault has said he despises the CHSLD abbreviation.)
Improving existing CHSLDs, Dr. Charpentier noted, was mostly absent.
Mr. Legault has apologized for Quebec’s elder treatment. At least 2,100 CHSLD workers have called in sick or not showed up for work. Mr. Legault has given those who work pay bonuses and promised more to come.
Dr. Lavoie, Dr. Guberman and Dr. Charpentier have each heard promises many times in decades studying the care of Quebec’s elders.
“I fear that the economic fallout from the pandemic will once again ensure we don’t invest in residences,” Dr. Charpentier said. “I’ve seen a lot, and I’m really afraid nothing will change.”
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