Post-COVID-19 community integration: the case for equity by design

Editor’s Note: This column is sponsored by AARP Thought Leadership and International. AARP Thought Leadership and International drives the creation of a marketplace for new ideas by advancing emerging issues, challenges the status quo and inspires new solutions that empower people around the world to make the most of a longer and healthier life.

A few months into the current pandemic, morning newspapers illuminated unflattering truths about our society. COVID-19 has exposed how the United States has systematically reinforced the creation of underserved groups of people—namely, people of color, immigrants and older adults. We have done this in many communities by physically segregating people of different ages and backgrounds over a number of decades and often disinvesting in the places where they live. These are the groups of people who disproportionately have died from the coronavirus.

Institutional Long-Term-Care

Modern industrial economies have all developed a market sector based on the institutionalization of older people. The COVID-19 pandemic is challenging this status quo of how we deliver long-term care in this country in unprecedented ways. Nearly half of coronavirus fatalities in the United States and Europe have taken place in long-term-care facilities, raising concerns about fundamental structural elements of this facility-based model.

This should come as no surprise. For decades, regulations enforcement in these settings has been lax, and avoidable infection-transmission and preventable suffering and death have too often been allowed to persist. But COVID-19 has heightened the demand for meaningful change. In a post¬–COVID-19 world, we can no longer assume it makes sense to concentrate frail older adults in large buildings with non-private rooms. In addition to residents’ loss of privacy, autonomy and dignity, it is now clear that, from an infection-control perspective, these arrangements can be lethal.

It is not only advanced age that makes people disproportionately vulnerable in institutional settings. Nursing homes are where the lowest income and most diverse collection of people in America reside. In a disproportionate number of facilities, the majority of residents are ethnic or racial minorities, and most of them are “dual-eligibles” (i.e., qualifying for Medicare and Medicaid).

Yet, residents of such facilities are not the only marginalized people disproportionately harmed by the pandemic. The workers—largely women and people of color—who provide care for frail and vulnerable older adults are mostly low-income and poorly compensated relative to the value of their work. Too often they endure arduous commutes because nearby housing is unaffordable.

During this pandemic, our front-line healthcare workers often lacked access to effective personal protective equipment and testing, making them more vulnerable to infection and increasing the virus’s spread within the care facility and among the families and communities where they live. Although public pronouncements have deemed these people “essential,” the conditions on the ground belie this rhetoric.

Concentrations of Race and Poverty Many

communities of color that historically were “redlined,” or deemed a poor financial risk for loans or insurance, have faced continued housing discrimination and disinvestment, often leading to concentrations of poverty. These communities also frequently are beset by educational, health, economic and environmental disparities due to systemic discrimination.

Many of our healthcare “heroes” often contend with unsafe housing, lead contamination, poor quality drinking water and outdoor air pollution—all while confronting limited access to good healthcare for themselves and their families. Many of these communities also are food deserts, or are located at least a mile from nutritious food options, leaving unhealthful fast-food restaurants and convenience stores to fill the gap. Additionally, under-funded schools and inadequate transportation options become barriers to accessing good job opportunities.

Combined, these and other social determinants of health are responsible for approximately 80 percent of health outcomes in the United States. A recent study led by researchers at AmfAR, the Foundation for AIDS Research, found that social determinants such as employment, access to health insurance and care, and air and water quality were better predictors of COVID-19 infection and death rates among Black Americans than underlying health conditions. The coronavirus pandemic has shown us in no uncertain terms that segregating people in society by age, race, ability or ethnicity is a form of discrimination with direct and substantial impacts on health and longevity.

A Community Integration Strategy

The window that COVID-19 has pried open presents an opportunity to address and transcend the functional consequences of segregation, and to develop and implement a community integration strategy based on the enduring value of healthy, diverse and enabling communities. We must explicitly confront and respond to underlying racial-ethnic disparities to ensure that communities of color achieve health, safety and well-being for all residents.

We must build the foundation of a new, equitable, system of services and supports that is based on, and draws strength from, our homes and communities. This alternative delivery system can respond to longstanding issues in effective and sustainable ways and become the successor to the institutional model of long-term care.

A community integration strategy is one that takes full advantage of the assets in the community, including its older population. It facilitates regular engagement between older and younger residents—preschoolers learn from older adults while in turn brightening their days; young adults learn about and provide geriatric care while fulfilling community service hours; and shared public spaces allow older people to spontaneously engage with other community members, remaining a part of the life of their community. This strategy includes a variety of services, such as rehabilitation centers and other post-acute care settings located within the community where people live and have friends. It is enabling by design.* It is designed for the hundred-year life.

A community integration strategy must value the gifts and contributions of people from every background, use diversity as an asset and aspire to greater equity. These values, at least in principle, have existed in law for some time. The Fair Housing Act of 1968 directed communities receiving funding from the U.S. Department of Housing and Urban Development to “take significant actions to overcome historic patterns of segregation, achieve truly balanced and integrated living patterns, promote fair housing choice and foster inclusive communities that are free from discrimination.”

But few communities have acted to achieve this vision. At this juncture, we must prioritize the creation and maintenance of enabling built environments in low-income communities and communities of color, using these actions as a vehicle to properly address the needs of disadvantaged residents and workers, and alleviate the disparities that have arisen over many decades.

Creating Enabling and Equitable Housing and Multigenerational Communities

In December 2019, AARP convened a transatlantic conversation among global thought leaders in the built environment—planners, architects and developers—in collaboration with the Agile Ageing Alliance in the UK and the German Marshall Fund of the United States. Emerging from that gathering is a Statement of Principles that can serve as a framework to help us rethink the intersection of the built environment and the elemental need and right of all people to health and wellness. This framework must address the structural disparities that have limited the opportunities available to people of color.

Worthy ideas are matched with action and, to help spark that action, we invite you to join us in the coming months for the Equity by Design global dialogue series based on this set of built-environment principles. The dialogue series will connect leaders from a range of geographies and disciplines and help to bring forth a more equitable, community-based system of designs and processes that enable people of all ages and abilities to thrive in a post–COVID-19 world.

Join us for this series of discussions with global leaders around building and retrofitting homes and communities to welcome people of all ages and abilities from all racial, ethnic and economic backgrounds. Now, more than ever, creating communities that provide for the most vulnerable people and where they can thrive is the best way to build livable communities for us all.

*Built-environment strategist Esther Greenhouse in 2008 coined the term “enabling design” to create a shift from the status quo (designs that worked for the average height 20- to 40-year-old adult male, but forced everyone else to adapt) to leveraging the features of the built environment to enable all people to function at their highest level and thrive. Enabling Design shifts the focus from designing for a subset of the population to designing for all needs, abilities, and behaviors across the lifespan.

Stephanie K. Firestone is senior strategic policy advisor for livable communities at AARP International, in Washington, DC., and a Health and Aging Policy Fellow. She has been an equity thought leader and advocate for many years, having founded Israel’s first Arab-Jewish environmental nongovernmental organization.

Dr. Bill Thomas is a geriatrician, novelist, entrepreneur, playwright and performer who with Jude Meyers founded the Eden Alternative and Green House movements, which advocate for more humane long-term-care environments. He is now working with population-health pioneer Lifesprk to accelerate the shift toward home- and community-based services and supports.