March 23, 2026
Eldercide—And How to Stop It
Cultural critic Margaret Morganroth Gullette on systemic failures in US nursing facilities and how to prevent another tragedy
In American Eldercide: How It Happened, How to Prevent It, cultural critic Margaret Morganroth Gullette, PhD '75, argues that what unfolded in US nursing facilities during the first year of COVID-19 was a preventable rather than unavoidable tragedy, produced by policy choices, market incentives, and a culture that too often devalues older, disabled, and poor people. In this conversation, Gullette explains why she uses the stark term "eldercide," what distinguishes facilities that protected residents from those that failed them, and why even the reformers' wisest fixes won't work without a moral and civic shift she calls "the education of the heart".
You argue that the term "eldercide" is appropriate for what happened in the early months of the pandemic in nursing facilities. Can you explain what you mean by that?
I chose "eldercide" to indicate deaths that were not simply tragic or inevitable, but avoidable—the product of policy failures, institutional neglect, and systemic biases. Older and disabled adults residing in nursing homes made up fewer than 1 percent of the US population, yet among those 1.4 million residents, estimates of total deaths in the first year of the pandemic ran from 112,000 to 152,000. The brutal fact is: residents of nursing facilities died at a rate 26 times higher than people living in the community. Now, some residents were frail—but hundreds of thousands who got the virus recovered, resiliently. And the fact that 1,950 facilities (out of 15,744) reported zero COVID-19 deaths in 2020 shows that it was possible to protect them. Therefore, this catastrophe isn't about biology or age—it's about money, choices, and systems. That's why I use "eldercide": to shift the conversation from "the old die" to "these older adults died because we failed them".
You argue that system failures—federal, state, and private—made the disaster possible. What were the most consequential?
Responsibility begins with the federal government, which has unique obligations to nursing-home residents. In 2020, it did not provide PPE (personal protective equipment) or establish national standards for facilities, although from the first the risk to residents was known to be extreme. Congress could have mandated masks for nursing-home staff promptly. Instead, procurement devolved to the states, which competed with one another; hospitals were prioritized while the facilities, housing a relatively small, highly vulnerable, and geographically concentrated population, were left to scramble.
Regulatory choices compounded the danger. Inspections related to chronic understaffing—the main cause of neglect—were curtailed just when oversight mattered most. Owners took note: if there is no PPE, and rare inspections, there is less pressure to improve either. Meanwhile, relief funds were distributed with few strings, and many facilities did not use them to hire additional aides or raise wages—precisely what was needed to sustain safe staffing through a crisis.
Finally, we must address ownership and incentives. A significant and growing share of beds is controlled by chains and private-equity-backed entities that can use complex, "nesting-doll" corporate structures to move money—paying related-party real-estate trusts or management companies—while pleading poverty. The Medicaid system pays per resident, per day, almost regardless of outcomes. Unless regulators enforce staffing and transparency, these incentives reward what critics call "plundering," not care.
Some facilities did extraordinarily well. What did they do differently—and could those practices have scaled?
They treated residents as protectable. That meant acquiring PPE early and in sufficient quantities; maintaining stable, adequately paid, and often unionized staff; limiting room occupancy and using architectures like "Green House" models; and applying rigorous infection control. Many of the strongest performers were mission-driven—religious orders or nonprofits—rather than profit-driven chains.
Could it have scaled, despite the chaos in the nation? Yes, because the population in question—the 1.4 million people then in nursing homes—was small enough and concentrated enough to prioritize. If the federal government had coordinated supply chains and standards for this sector, if states had enforced staffing and transparency, and if owners had been required to show where every relief dollar went, the US could have saved many lives. The proof is in the outliers that succeeded.
What policy changes would make the greatest difference—soon?
First, staffing. Congress should set and states enforce meaningful hourly-care minimums, as President Joe Biden tried to do in 2024, for the first time in sixty years. Wage floors and fair working conditions retain indispensable aides. Whenever aides are overworked, medications arrive late, wounds go untreated, call bells ring unanswered, and burnout drives turnover—the core of neglect.
Second, transparency and accountability. Require public, standardized, audited reporting that follows every dollar—real-estate rents, management fees, executive compensation, related-party transactions—so regulators (and families) can see whether money is going to care. Tie payments to compliance. Stop rewarding opacity. Raise fines.
Third, shift the default. Expand home- and community-based services so that indigent, chronically ill, disabled, and older adults can avoid institutionalization, as most people wish. Where congregate care remains necessary, prefer smaller-scale, private-room models and mission-driven operators over financialized chains. And align federal-state authority for any emergency: coordinated procurement and enforced standards for a population that is cherished, and small enough to prioritize.
