Examining the Impacts of Coronavirus Disease 2019 Mitigation Policies on Health Outcomes of Older Adults: Lessons Learned From Six High-Income or Middle-Income Countries

Exposures to severe acute respiratory syndrome coronavirus 2 differentially impacted the risks of coronavirus disease 2019 (COVID-19) by age and by country. Regardless of the country, older adults aged 60 years or older with or without comorbidities were at higher risk of developing severe symptoms, being hospitalized, and dying from COVID-19 (Meftahi et al., 2020; Perrotta et al., 2020; Wortham et al., 2020; Yanez et al., 2020). Higher COVID-19 death counts were observed consistently among older adults in comparison to younger adults across high-income and middle-income countries, with large variations for absolute reported death counts (United Nations, 2020). In the United States, deaths surpassed one million, whereas in Japan the death count has been at least 31,466 as of July 13, 2022. (Statista, 2022). There were considerable differences in COVID-19 mitigation and control policies in countries that used a centralized, top-down approach (e.g., Japan, India) versus those that used a decentralized, bottom-up approach (e.g., Canada, the United States, Brazil, Russia), with unique within-country aspects (i.e., socioeconomic, political, and cultural challenges; underlying population distributions; age structures; and male-to-female ratios) that impacted the absolute death counts (see Figure 1; Vervoort et al., 2021). For example, every country had a unique health-care system and a unique public health infrastructure that led to differences in COVID-19 local implementation responses, with some countries being more relaxed about mask mandates and restrictions. These shortcomings in policy appeared to impact the most vulnerable (i.e., older adults). Additionally, within countries, COVID-19 infections occurred in waves and manifested differently in terms of timelines, in how threat levels were perceived for older adults, and in the proportions of COVID-19 cases and deaths among older adults (see Table 1). Characteristics of high-income and middle-income countries and their COVID-19 policies for older adults Note: COVID-19 = coronavirus disease 2019; HI = health insurance; LTC = long-term care; N/A = not available; OECD = Organisation for Economic Cooperation and Development. Sources: Japan Ministry of Health, Labour and Welfare, 2022; Ritchie et al., 2022; Statista, 2022; Statistics Bureau of Japan, 2021; U.S. Centers of Disease Control and Prevention, 2022a, 2022b, 2022c;,World Health Organization, 2022a, 2022b, 2022c; Worldometer, 2022. aOfficial death statistics might be underestimations of the actual deaths in India and Russia. Characteristics of high-income and middle-income countries and their COVID-19 policies for older adults Note: COVID-19 = coronavirus disease 2019; HI = health insurance; LTC = long-term care; N/A = not available; OECD = Organisation for Economic Cooperation and Development. Sources: Japan Ministry of Health, Labour and Welfare, 2022; Ritchie et al., 2022; Statista, 2022; Statistics Bureau of Japan, 2021; U.S. Centers of Disease Control and Prevention, 2022a, 2022b, 2022c;,World Health Organization, 2022a, 2022b, 2022c; Worldometer, 2022. aOfficial death statistics might be underestimations of the actual deaths in India and Russia. Population pyramids by country for the year 2020. Percentages of people are shown on the horizontal axis and the black line is a projected median estimate for the year 2050. Sources: United Nations, Department of Economic and Social Affairs, Population Division, 2022a, 2022b. Consequently, there was no global systematic approach or “one size fits all” solution to contain COVID-19. As a result, a non-unified global approach to handling COVID-19 allowed different countries, provinces, and states to adopt strategies that would work best for them. Big waves of COVID-19 infections caused each location to enact their own protocols for lockdowns and quarantine when the resources of one country did not line up with those of another (Hofman, 2020). However, when cases spiked exponentially in some areas, the spike stressed the need for nationwide regulations in areas where people could transport from state to state. As a result of the approaches and strategies adopted, some countries effectively reduced their rate of infection, while others could not. Some countries successfully implemented stringent travel restrictions or extreme shelter-in-place measures, while others struggled on multiple fronts, such as the following: a lack of consensus on mask-wearing mandates, construing social and physical distancing policies for public health good in nursing homes and in community settings as authoritarian, national opinions about data sharing and sharing of vaccine technology, sharing global supplies to manufacture vaccines, trust in science, widespread misinformation, and economics fears. While both unified and non-unified responses had pros and cons, each country’s overarching health-care policies and specific COVID-19 policies had positive and negative impacts on its older population. While both unified and non-unified responses had pros and cons, each country’s overarching health-care policies and specific COVID-19 policies had positive and negative impacts on its older population. The variations in policies across countries and the varied older-adult mortality rates motivated our team of international scholars to: (a) examine the reasons for the varied COVID-19 responses across six high- and middle-income countries that adopted either a centralized approach (i.e., Japan, India) or a decentralized approach (i.e., Canada, the United States, Brazil, Russia); (b) highlight country-specific policies that were favorable and unfavorable for older-adult well-being or mortality; and (c) highlight country-specific policies that were favorable and unfavorable for vaccine uptake. In summary, we provide lessons learned and highlight recommendations to improve older-adult well-being and reduce older-adult mortality during pandemics. Nearly one-third (28.9%) of Japan’s population of 126 million is an older adult (Statistics Bureau of Japan, 2021). Of the 9.2 million cases, 11.7% of cases—and within cases, nearly 90% of deaths—were among those 60 years and older, and nursing homes accounted for nearly 14% of overall COVID-19 deaths. Despite being a super-aging society, Japan had the confirmed absolute deaths and deaths per million (total) as of July 13, 2022 among the six countries we reviewed. Early in the pandemic, Japan introduced COVID-19 control policies providing a nationwide, unified, centralized guidance for COVID-19 countermeasures. A state of emergency for the first 29 days was declared based on surveillance, medical service responses, and epidemiological evidence. Key elements of the emergency response included the following: (a) the provision and sharing of information; (b) surveillance and information gathering; and (c) pandemic prevention. These measures were successful in reducing rate of new and cumulative cases to 0.5 infections per 100,000 early in the pandemic, i.e., by 26 May, 2020. The current infection rate of 47 per 100,000 as of September 24, 2022 remains low but higher than what it was in 2020. Additionally, favorable policies, such as stay-home “requests”; the closure of facilities, including restaurants; access to polymerase chain reaction tests; online support services; and requisitions of land or buildings for medical purposes, were instrumental in controlling the viral spread. However, unfavorable policies, such as the closure of adult day care centers and lockdowns of recreational and gathering facilities by the government early in the pandemic, likely increased social isolation among older adults. Nevertheless, the lockdown was perhaps instrumental in keeping the burden of mortality low among older adults. Next to health-care workers, older adults ≥65 years were prioritized for a massive vaccination program, both among those in the community and those institutionalized, with implementation of vaccines for older adults accomplished in four months (Abe & Kawachi, 2021). In Japan, the preexisting universal health coverage since 1961 and the universal long-term care (LTC) insurance coverage since 2000 served older adults well throughout the COVID-19 pandemic; these programs helped to cover a range of pandemic-associated treatments and rehabilitation and to implement an effective vaccination program (Alencar et al., 2021; Health and Welfare Bureau for the Elderly, 2016; Japan Health Policy NOW, n.d.). India, with a population of 1.4 billion, had 43 million COVID-19 cases and 525,825 deaths, which were grossly undercounted but led to India ranking second in the number of COVID-19 cases, after the United States (Goldstein & Lee, 2020; Ministry of Health and Family Welfare, 2022). In India, 9% of the population (100 million adults) is over the age of 60, with half of the those in this age group in the lowest income group (Nagarkar, 2020). Despite its relatively younger population, the premature onset of chronic conditions among adults >45 years is common in India (Goli & Arokiasamy, 2013; see Figure 1). This partially shifted the share of COVID-19 mortality from older adults to younger adults ages 40 to 60 years. Additionally, undiagnosed older adults with multiple chronic conditions remained vulnerable to COVID-19 (Arokiasamy, 2018). Consequently, the age-wise COVID-19 mortality rates showed mortality among older adults >60 years to be nearly 50%, with 46% of all COVID-19 deaths in India observed among adults ages 30 to 60 years and a median age at death of 60 years. India required a unified, national, centralized response to COVID-19, and its government was proactive in initiating a nationwide lockdown early in the pandemic. However, this stringent implementation without a safety-net provision for low-income groups and migrant workers had serious repercussions on the health of population subgroups due to food insecurity. The lockdown affected older adults, who did not receive timely health care and who were already struggling with loneliness, restricted mobility, poor health, inadequate access to medical facilities, and financial insecurity (Nagarkar, 2020). Those in rural areas were more severely affected, with loss of income due to job loss and with a lack of health coverage. In India, 6% of older adults who live alone are dependent on caregivers and helpers who visit daily (HelpAge India, 2018). The pandemic limited the movement of caregivers and increased social isolation among older adults. The second wave of the COVID-19 pandemic was fueled by mixed messaging from the government, allowing people to attend religious gatherings, political rallies, social gatherings, and weddings. Nevertheless, the vaccination response of the government was favorable, with India counted among the few countries manufacturing its own vaccine. The government was successful in implementing a wide vaccination campaign and achieved a high vaccination rate among its population, thereby curbing the mortality rate (see Table 1). The government of India peaked the vaccine development by engaging in proactive risk financing on an enormous scale, clearing roadblocks, and strengthening the end-to-end systems in vaccine development, manufacturing, and distribution. The strategy to inoculate individuals with 30 core high-risk conditions, including prioritizing older adults, led to a reduction in mortality and to India gaining population-level immunity against the virus before further waves hit the country. Yet, the pandemic exposed India’s inadequate public health-care system and safety-net infrastructure, with wide variations across states. The varied COVID-19 responses by Indian states can perhaps be attributed to the inherent disparities in the resources devoted to their health-care delivery systems. More developed Southern states, such as Kerala and Tamil Nadu, which had better health-care infrastructures and higher literacy, reported lower mortality rates in comparison to less developed Northern states, such as Rajasthan (Ministry of Health and Welfare, 20202). The pandemic magnified the existing health-care disparities and called for serious government action to strengthen and invest heavily in India’s public health infrastructure, address inequities in health-care access, and provide timely and quality care that can equip the country better for future emergencies. Canada, with a population of 38.4 million, reported 3.9 million COVID-19 cases and 42,219 deaths; 18.5% of its population consisted of older adults. While the provinces in Canada implemented decentralized COVID-19 responses and strategies for pandemic containment and mitigation, there was considerable cooperation between the federal and provincial governments, with minimal political polarization. Canada’s three territories and ten provinces coordinated containment, mitigation strategies, testing, and contact tracing, while the federal government secured the borders and provided support for the national stockpile of protective equipment, testing kits, and ventilators (Detsky & Bogoch, 2020). Canada closed the land border with the United States for the first time since Canada was founded, and interprovincial travel was discouraged. Canada’s favorable policies to prevent widespread community transmission were consistent and characterized by partnership with citizenry, trust in science, and cooperation across levels of government (Detsky & Bogoch, 2020; Haffajee & Mello, 2020). However, in the early stages of pandemic, due to a limited supply of vaccines, provinces differed in how they rolled out the vaccines to their older-adult populations. For example, the early and complete vaccination policy of Alberta for its older-adult population was beneficial, in contrast with the Ontario policy prolonging the interval between doses to maximize limited early supplies. Failures in effective prevention control measures and staffing led to nearly 80% of resident deaths occurring in LTC facilities in Ontario and Quebec (Detsky & Bogoch, 2020). Later in the pandemic, the favorable vaccination policy in Canada, including prioritizing vaccination and boosters for older adults, was successful in fully vaccinating over 95% of Canada’s older adults. The United States, with a population of 332 million, reported the highest number of COVID-19 cases, at 90.7 million, along with more than 1 million deaths. At least 7.4 out of 10 COVID-19 deaths occurred in adults ages ≥65 years. At least 31% of deaths occurred in LTC facilities, with high rates of COVID-19 cases and deaths in nursing homes (AARP Policy Institute, 2022; The New York Times, 2021). The decentralized public health-care system of the United States is comprised of both the federal and state governments, where the federal government plays the role of oversight and regulation, while the state and local governments, including county governments, are in charge of implementation of the health-care policy. Early in the pandemic, major cities in the United States were hotspots for COVID-19 outbreaks and, to control and mitigate COVID-19, states implemented varied approaches. Masks and face coverings were made mandatory in public places in certain states, while others reopened with measures continuously evolving. For community-living older adults, special, priority grocery shopping morning hours were established. Additionally, a certain degree of collective compliance in safe physical distancing measures and appropriate use of personal protective equipment was employed. However, an initial lack of accessibility to Food and Drug Administration–approved COVID-19 tests and antigen tests, the subsequent proliferation of faulty tests with poor sensitivity (later recalled by the Food and Drug Administration), and shortages of personal protective equipment in the LTC settings and in the hospitals failed to control and mitigate the viral spread. These limitations also precluded the ability to discern a denominator and led to unreliable statistics with which local officials could mandate certain public health measures. 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