A new study in the Lancet Healthy Longevity suggests that older residents in Sweden who lived in care homes had the highest mortality (233 deaths per 1,000 people per year), followed by those living in apartment blocks (26 deaths per 1,000 people per year), and those living in a detached house (16 deaths per 1,000 people per year). Outside of care homes, older Swedes who lived in multigenerational or crowded homes were more likely to die (73 deaths per 1,000 people per year), compared to the least crowded homes (22 deaths per 1,000 people per year). After adjusting for age, sex, education, income, and country of birth, those living in care homes were four times as likely to die of covid-19 than those living in independent housing. Elderly persons living in the most crowded households were twice as likely to die of covid-19 (as well as other causes) than those in the least crowded homes.

Results in Sweden may not apply to the US. Differences in life expectancy in Sweden and the US (83 versus 80 years) suggests somewhat worse health in America. US nursing homes are often run by for-profit corporations, although another retrospective study from the US suggests that excess mortality does not depend on the ownership of a nursing home.

Mortality is predictably higher among elderly who live in care homes due to both the health of the residents and the crowding of the frailest members of society. People in nursing homes are clearly vulnerable and we must remember that they are owed the best possible care.

An important contribution of this new article is to separate the living situation from other factors, highlighted by the finding that mortality in the elderly people living in nursing homes exceeds mortality in those living in crowded multigenerational homes. The implication is that some excess mortality in nursing homes is preventable.

The numbers are stark. In nearly every state covid-19 cases are climbing. The average number of deaths per day is up ten percent. The White House Chief of Staff has said the virus is "beyond control." But even this does not paint the entire picture. Cases have been surging for the past few weeks, and public health experts agree that death counts are a lagging indicator, often trailing several weeks behind the current case data. As the weather turns colder, the fear is another surge of need for hospitalization and critical care that threaten to swamp hospitals.

But the danger is not just in the lack of physical resources; rural centers have been hit especially hard with healthcare worker infections, further limiting already strained systems without a ready source of replacement personnel. Discussions are already underway regarding again limiting elective procedures and clinic visits, but there is no way to compensate for staff quarantines. With a vaccine candidate likely not available until early next year, the one option available is finally taking seriously the long-standing social distancing and masking guidelines advocated for by leading experts. Various.