This article was published in Mouvements magazine in March 24, 2021.

In the early spring of 2020, the humanitarian organization Médecins Sans Frontières (MSF) launched a mission in nursing homesIn France, Ephad  (établissements d'hébergement pour personnes âgées dépendantes) are nursing homes for elderly people. These facilities can be both public and private. Most of them do not have permanent medical staff. The use of "nursing homes" in this interview refers to these establishments. in the Ile-de-France region, which had been hit hard by the Covid-19 pandemic. After considering the implementation of night-time palliative care, the organization finally decided to provide daytime support to the nursing homes in difficulty. Once the crisis was over in the summer, the MSF teams started offering mental health support to nursing home staff. A look back at this experience on September 28, 2020 with four members of the mission, Olivia Gayraud (project coordinator), Jean-Hervé Bradol (M.D. and CRASHCentre de Réflexion sur l'Action et les Savoirs Humanitaires (CRASH) in the Fondation Médecins Sans Frontières. member), Marie Thomas (psychologist) and Michaël Neuman (CRASH coordinator).

Mouvements: How does an international humanitarian organization find itself working in the spring of 2020 in France's nursing homes? It is an environment that does not correspond to the idea of an MSF mission. How did you decide that this was the right place to go during the health crisis?

Olivia Gayraud: A few of us quickly realized that many severe cases and deaths were taking place in nursing homes and that these establishments were not only suffering from the virus but were also contributing to its spread. The Covid-19 virus started spreading from nursing homes to the roads, to transport, to supermarkets... We wanted to do what we usually do in case of an epidemic: focus on the most infected places. However, MSF is not known for its work with the elderly. We are recognized as having expertise in epidemic management but geriatrics is not our field. We therefore started small with a crisis unit set up specifically for Covid-19 in the Val de Marne region and then we intervened in the Hauts-de-Seine, Seine-Saint-Denis and Paris. At the same time, there was a lot of internal reluctance; some people thought that it was not MSF's role to intervene in a country like France because the government had the means. The image of nursing homes as private companies that charge exorbitant fees was also a hindrance.

Jean-Hervé Bradol: We are in an institution, MSF, which was initially reluctant to take an interest in what was happening in France. In March, our directors stated openly: in France, there is a plethora of resources; if our French colleagues ever call on us, we will respond but we will not have an active attitude towards problems.

The trigger was the experience of Claire Rieux, a hematologist at the Henri Mondor University Hospital (Créteil), who is also very involved with MSF. The directors of this university hospital quickly noticed that she had developed experience with MSF in emergency and disaster medicine. They invited her to the crisis unit of the university hospital where she gave simple and practical advice. For example, in the hospital pharmacy: in order not to be paralyzed if the hydro-alcoholic gel is not delivered, it is advisable to start producing it as we have all the ingredients and the necessary expertise. Claire encouraged the management to get things started as soon as possible and to be pragmatic, and her role was appreciated. She mediated between the hospital and MSF. Henri Mondor's initial request was for palliative care at night. In the administrative sense of the term, this means a night that lasts 12 hours a day. The nursing homes were experiencing deaths and had few or no night nurses, and the crisis unit was looking to set up a mobile on-call team that could support the nursing assistants who were alone at night in these late-stage situations. At MSF, we began by meeting a team set up by the Henri Mondor University Hospital: geriatric doctors who provided telephone support through a dedicated number, medical students and a SamuMobile Emergency Medical Service. manager. This team was clearly looking for solutions to reduce the pressure on the Samu and the hospitals, so that they would not be "bottled up" by this type of case. They were quite transparent about the fact that their concern was to avoid that residents of nursing homes arrived to hospitals. In a dialogue recounted by our colleague, with a family insisting on having the Samu come and transfer a seriously ill elderly person to the hospital, the team put it this way: "We are willing to take her, but it is better to die comfortably in a nursing home than to die on a stretcher in the corridor of an emergency department. This picture painted by our colleague from the Samu corresponded to the saturation of certain hospitals in March-April. We are not talking about intensive care beds, which most of the time do not correspond to the needs of the residents of nursing homes, but about simple acute geriatric beds for the management of the infection and, eventually, end-of-life care. On the other hand, in the nursing homes, the staff told us that they had few means to support people in the final stages of their lives, that a nursing home bed is not the same as a hospital bed, and that acute care is difficult there. Even in the nursing homes where one manages to put people on oxygen and antibiotics - measures that allowed some residents to survive - one was still far from the standards of a geriatric hospital bed. The mission was born out of this discrepancy between what the nursing homes were asked to do and what they could do.

Olivia Gayraud: What struck me and motivated me in this mission was the glaring absence of medical presence in the nursing homes. Some institutions no longer had coordinating doctors, many were elderly and therefore had to confine themselves, others had simply fallen ill. The city doctors who follow the residents were no longer coming. There was no continuity of care, even though these are very old people with serious chronic pathologies. As for the situation at night, it was a real call for help. Caregivers found themselves alone to accompany elderly people who were dying in extremely difficult circumstances. I found it terrible that there was such a lack of access to care, such poor treatment of the elderly and the staff in a country like France. The nursing homes were asked to become care units, but without logistics, without resources and without competence. Once the problem was diagnosed, we set up a mobile medical team and went to visit the nursing homes that had been identified and that agreed to receive help.

Jean-Hervé Bradol: We started the interventions on April 6. For us, these visits were first and foremost a gesture of solidarity towards our fellow caregivers and staff. For the institutions that agreed to open their doors, these meetings were gratifying for them as well as for us. Together we assessed the situation: was the virus present among the residents? If so, how many cases? What could be done to isolate the positives? What staff was available? What did they need to deal with the crisis? We also gave them scientific and political information. Since February, the staff and management of the nursing homes were so overwhelmed by the tasks they had to accomplish that they did not have time to read the scientific press or even watch television. So our first task was to be up to date so we could respond to them. They were presented with procedures on how to take off their shoes and clothes to make sure they didn't bring the Covid-19 virus back to their children or their spouse. Our team doctor would perform consultations for patients who were brought to her attention by staff as problem cases.

Mouvements: For someone who has worked in other humanitarian missions, what struck you about the situation in the nursing homes in France?

Olivia Gayraud: First of all, the fact that what they were going through was not completely new for them. Nursing home staff had already experienced episodes of epidemics, flu or gastroenteritis, when they were unable to admit residents to hospital because of a lack of available beds. What happened in the spring was the exacerbation of an institutional crisis that had already been present for several years. With Covid-19, the number of people affected was out of all proportion to previous episodes: sometimes, in the same institution, there were as many as thirty or forty very sick elderly people. Secondly, there was a severe shortage of staff and the protocols were impossible to follow. Some of the staff were infected or had fled for fear of being contaminated. When you have two caregivers for 90 residents, even comfort care such as toileting cannot be done properly. Finally, these places had become true viral bombs. Our priority was to protect ourselves from spreading the virus; unfortunately, we did not have enough material to give to the nursing homes. This was a crucial issue, especially as there was a lot of theft of protective equipment: the staff sometimes work in several institutions and some of them stocked up to make sure they had a mask or a gown in the next place. We quickly found alternatives to make up for the shortages, with cloth gowns for example, but the atmosphere was particular, as even the smallest bottle of hydroalcoholic gel would disappear.

Jean-Hervé Bradol: What struck me was the discrepancy between the obsession with resuscitation beds at the national level, while on the ground, what the residents of the nursing homes needed were simple hospital beds with oxygen and a few standardized prescriptions or palliative care. And then on March 28, Olivier Véran, Minister of Health, asked that people be confined not only in the establishments but in their rooms.

Mouvements: What happened to the residents of the nursing homes who were confined to their rooms? What were the consequences for the people?

Jean-Hervé Bradol: Let me give you an example: a man and his wife, who lived in the same nursing home, had been ill and had recovered. They were forbidden to see each other even though they were no longer at risk. This type of authoritarian decision was a daily occurrence. Locking people in rooms was a simple, global, straightforward decision, but a dangerous, murderous one too. Limiting people's days to functional visits, for care that is often poorly done, brutally executed for lack of sufficient staff, is extremely cruel. I am willing to find excuses for the government, because during a disaster, situations are difficult to analyze and decisions are complicated to make. But when it comes to locking up old people, it is unforgivable. Locking people up in their rooms 24 hours a day, nobody has that power, no emergency health situation gives that kind of power to public health. The residents had expressed specific requests to be able to meet other residents or to maintain a relationship with their loved ones at this critical moment in their lives. But listening to the elderly in the nursing homes was never on the agenda. In spite of the overwhelming support of the residents, a director of a nursing home had to dismantle a system of visits for relatives under pressure from the regional health authorities. Few people found anything to say about it, especially among the big shots, the great professors of resuscitation that we heard all day long on television.

This resonated with other experiences of incarceration or confinement in places like prisons or orphanages that we encounter very regularly as humanitarians, experiences with often catastrophic consequences. I remember a public orphanage in Khartoum, Sudan in the early 2000s. The infants were fed with metal cups because for UNICEF, the bottle is the devil, it is a vector of infections. Feeding a baby with a cup or a spoon is perfectly possible, but you have to be extremely careful not to let the contents get into the lungs. Here, this was not the case and many died from false routes or poor treatment. With this feeding system, the children were never held by the nannies, they had no close body contact, and they were in total lack of affection. A board ran the institution and whenever there was a problem, the nannies were used as the ideal culprit, nobody listened to them. The board was made up of well-meaning notables, all of whom were charitable, while the president was a professor of child psychology at the university! And they were at the head of an institution where mistreatment was the norm, along with drawings of Mickey Mouse on the walls. Of course, the situation of the nursing homes in France in the spring of 2020 is not similar, but there is a parallel to be drawn around the disastrous health consequences of confinement.

Marie Thomas: Those who suffered the most were those who initially had the least cognitive problems and whose condition worsened considerably during the crisis. The confinement was deadly on the psychological as well as physical level. Today (in September 2020), there are no more national instructions, the state has unloaded on the managements by telling them that it is up to them to decide if the confinement continues or not. This is a huge stress and responsibility for the teams. There are places where we arrive at ubiquitous situations: if the director leaves for the weekend for three days, we lock up for three days and then reopen...

Mouvements: Was the situation different depending on whether it was a public, associative or private nursing home?

Olivia Gayraud: We had access to all types of nursing homes and there were differences in terms of accommodation but not in terms of care.

Jean-Hervé Bradol: Class barriers were broken down during this crisis in terms of the quality of medical care. From this point of view, the Parisian nursing homes, which are on the whole rather chic, have been very hard hit. Regarding the difference between for-profit and not-for-profit establishments, there has been a lot of talk in the press about the Korian group, but from what we have been able to observe, it is not necessarily there that the situation has been the worst. In private for-profit nursing homes, these sometimes rather cynical profit-making companies, there is a very strong reputation issue. On the other hand, they had the financial clout to mobilize budgets and buy masks, for example. This was not possible in some associative nursing homes that were not members of powerful federations.

Mouvements: The mission shifted from care in response to an infectious emergency to the mental health of the nursing home teams, how did this happen?

Marie Thomas: From April to June 2020, with the medical team, I led the exploratory phase on the mental health dimension. From the start, our fear was that the elderly would not only die from Covid-19 but also deteriorate in cognitive, neuropsychological terms with the risk of "slippage syndrome", the risk of suicide or non-return after cognitive deterioration. We knew that we could not set up a mobile unit of psychologists to visit the 700 nursing homes in the Ile-de-France region and provide consultations to all the residents. So we said to ourselves: "How can we increase the mental health skills of caregivers so that they are better able to identify and assist residents in risky situations?" We worked on intervention modalities with the psycho-social support team that deals with MSF staff. I started to go with the medical and paramedical teams to make small, very basic interventions on how to take care of one's colleagues, one's team, yourself, how to listen to oneself. This had an almost disproportionate effect on the teams, it was the first time that they had sat down and been told thank you and congratulations for what you were doing. There was a lot of emotion, I saw some group collapse.

This led us to set up the project along several lines: discussion groups for the staff, training for the caregivers and support for the executive and management teams. We quickly realized that the latter also needed help and that there are not only "bad" managers. We met people who did not see their children for 3 months, who slept on the premises, who fed people in their rooms. And this, I did not expect. People who were also suffering. I saw directors who were breaking down and saying, "We know what's wrong, but we don't know how to deal with it.

It took us a little while to get the budgets internally at MSF and we started the first discussion groups for the staff in mid-July. Our desire was to act in the post-crisis period. We know that it is after the crisis that there are the most psycho-social risks such as burn out, post-traumatic stress and suicide. Unfortunately, this has been totally confirmed here. All this with the understanding that the post-crisis period in the Covid-19 is a term to be taken with a grain of salt; let's say a low point in the progression of the pandemic. Echoing the interventions of the medical and paramedical teams, we quickly identified the need to support the night teams: people who are even more precarious than the day staff, whose specific rhythm makes their access to psychological care more difficult. This debriefing time for the night teams is I think one of the best ideas of the project.

Olivia Gayraud: Those who came to the discussion groups were mostly precarious workers, care assistants, cleaning staff, kitchen assistants, who sometimes work in short days, getting up very early and going home at 10 pm, some of them working part-time and with very limited career development. They would probably not have had the idea of consulting a mental health professional, nor the financial means to do so. 

Mouvements: What were the causes behind the suffering of the nursing home staff?

Marie Thomas: In the group interviews, the people allowed themselves to share a raw and violent experience, with traumatic symptoms. The expression "ballet of coffins" came up many times. In the most affected nursing homes, there were as many deaths in 10 days as there usually are in 18 months, it is normal not to be able to assimilate and accept this. Especially since the relationship between the staff and the residents is not at all the same as in the hospital. They - knowing that 80% of them are women - often talk about "their residents" and call them by their first name. At first, this is surprising, but there are great bonds in these places with people who see each other every day for years and share the joys and sorrows of daily life. They refer to the body bags as garbage bags in which people have been put, and the inability to accompany the elderly to death. They are used to doing this. But in this case, they were not allowed to carry out mortuary cleaning, to dress the deceased, to put their personal belongings in the coffin. And that's something that is not assimilated by the teams and I don't know if it should be. That's what traumatizes them the most. In the elderly, there were a lot of digestive forms in Covid-19, with these people who were emptying out, dehydrating because of severe diarrhea. The person was in bed, died, and it took three hours to get to them. This is intolerable. They took care of the living that were left. They themselves had to learn to prioritize when that is not at all what they should have to do.

They describe extremely intolerable and shocking scenes, especially in the nursing homes where there was a lack of oxygen. Bodies found blue on the floor, people curled up in fetal positions (a sign of pain), things that are difficult to hear even for us. The reminiscences are also auditory: the sound of coffins being sealed, a memory that is evoked by many as unbearable. The refusal of the Samu to come to the scene was also very badly experienced by the teams. And despite this trauma, it was necessary to continue to work over a long period. Many people talk about changing jobs, taking early retirement, taking sick leave.

Jean-Hervé Bradol: It's a classic in disasters, to dispose of bodies in a careless way because there would be an epidemic risk. What we get every time is an epidemic of psychological disorders due to hindered mourning that is often more severe and more frequent than the contamination by germs that are supposed to be prevented by these precautions. A technique had arrived from the East of France: preparing intra-rectal syringes of Diazepam, a psychotropic drug, for the nurses' assistants to improve the end of life of the patients. The doctors talked about it as something positive, as a way to get out of it... However, it is not the caregivers' job to do that, even a doctor should not do it alone. When you think of those caregivers left at night to write an end-of-life prescription that symbolically evokes a kind of "euthanasia" - even if I'm putting quotation marks on it - you can see how difficult the aftermath is.

I wondered about the difference between the elderly who are in nursing homes and those who are at home. The difference is the dependence, the handicap. The elderly who are at home are not so disabled that they can no longer stay at home. One of the sacrifices that society made at the beginning of the Covid-19 pandemic is a classic sacrifice in times of crisis, the sacrifice of people who live with a disability.

Marie Thomas: I'm bouncing off of that in terms of words that staff uses in the focus groups. In six different groups, in six different places, people compared what happened to the elimination of disabled people by the Nazis. This comparison shows how violent what they experienced was and how they felt abandoned by the rest of society.

Mouvements: Finally, in society as well as at MSF, devoting resources to caring for the elderly during the epidemic was not an initial consideration. Do you have any hypotheses to explain this?

Jean-Hervé Bradol: Indeed, our own organization gave us the impression of going backwards. We felt this particularly with regard to the protective equipment that we were given sparingly, even though at the beginning we were only a small team of four people. MSF did not provide any medicines, even though we were aware that we were in danger of being stuck with patients at the end of their lives with nothing to help them get through. We had to make other arrangements.

Michaël Neuman: What happened at MSF is a reflection of what is happening in society. There is no sufficiently powerful lobby to defend the interests and rights of the elderly at MSF in the same way that there is none in the rest of society. There is also a question of resource allocation: when one thinks of priorities, it is not France and even less its elderly who come to mind first. Even when MSF decided to take an interest in Covid-19 in France, we started by going to our usual targets, the migrants on the street with whom we have been working in France for a long time, and as an organization, it took us some time to understand that this was not necessarily the place where the epidemic was the most deadly. Even with regard to protective equipment, despite the need for equipment for the nursing homes, we were very sparing in keeping stocks for the next wave of Covid-19 that would hit our usual countries of intervention - which did not happen for some, particularly in Africa. For a long time, we were convinced that France would make it and that there was no reason why it should not.

However, it is important to underline one point: the fate of the residents of the nursing homes and of the dependent elderly in general arouses more reactions in other European sections of MSF. In Belgium, Italy and Spain, the presidents, directors of operations and teams have shown a greater appetite for taking an interest in the situation of dependent elderly people. They have made themselves available to the public authorities for intervention, who have also approached them more directly. In Italy, this can be explained by the fact that it is a section that is not in charge of operations and therefore the intervention was not in competition with others. This explanation is not valid for Belgium and Spain, which, like France, have an important operational component. One possibility is that in these three countries, unlike France, there are no or very few interventions on national soil. The elderly public did not replace a regular public.

Jean-Hervé Bradol: Another possibility is that in Belgium, as in Spain, the leaders of the countries accepted the idea that they had been overwhelmed by the events. In France, the official discourse was: "the hospital has kept going", there was never any recognition of the fact that they had been overwhelmed by the situation. The doctrine of the infallibility of the State and its correlative, the French health care system as the «best in the world " (sic), prevailed throughout the crisis. The public authorities never suggested that they needed help, and they even managed to make it seem as such.

Mouvements: We are in September 2020, how do you approach the next step?

Olivia Gavraud: We remain very worried, there are 400,000 people working in nursing homes and 730,000 elderly people at risk.

Jean-Hervé Bradol: You give these figures and I say to myself: at MSF, we have a policy towards the most vulnerable, children under the age of two, pregnant women, groups at risk such as the latest arrivals in a refugee camp. We know that in a crisis situation we cannot respond to all the needs, so we focus on them. Well, in this crisis, the biggest group at risk was not so difficult to identify, they were grouped in the nursing homes, we even had their addresses. That they were forgotten last winter, that it took time to identify the problem, we can understand but now it is no longer acceptable, they must be subject to specific protection measures. The arrival of the first vaccines will re-launch the debate, because the residents of nursing homes will be in a position to be among the first to benefit. This could be an opportunity to broaden the debate on the institutional policy to be put in place on a permanent basis for this vulnerable group, particularly in terms of care coordination. As a neophyte in geriatrics, even before examining the patients, simply by looking at their files, I was astonished by the medical complexity of the situations, very old people with numerous co-morbidities, organ failures, losing their autonomy. Very difficult cases, in institutions where there is no night nurse in the standard staffing. While a lot of money is spent on care, it is not coordinated in a satisfactory way. This is reminiscent of countries like Saudi Arabia where there is often no care plan, just a juxtaposition of specialists who run machines, medical "mercenaries" who intervene on an ad hoc basis, resulting in a very low quality of care.

Marie Thomas: What worries me today is that usually when we set up a work with people who have suffered a trauma, we can say that the event is over. It's never that simple and linear, but when there's an attack or a natural disaster, you can in therapy rely on the fact that it may not happen again or at least not right away. With Covid-19, we can't tell the staff that this is all behind them, it's not possible and the worst may still be ahead of us.