COVID-19 lockdown: the unspoken toll on the 65þ community in

Ozgur Ates

Abstract Ozgur Ates is based at the Purpose – On March 21, 2020, the Turkish Government imposed a curfew for citizens 65 years old and Department of Business over and ordered them to stay at home as a measure to protect them against the COVID-19 outbreak. The Administration, Faculty of curfew ended on June 10, 2020, having lasted 82 days. The purpose of this paper is to examine the Political Science, Ankara significant emotional burden on the elderly, as they felt excluded and battled with despair during the University, Ankara, Turkey. lockdown. Design/methodology/approach – This reflective paper shares the COVID-19 lockdown experiences of the author with a group of elderly residents of a small community in Ankara, Turkey. Through semi- structured interviews and analysis, three overarching themes of the residents’ experience were identified: vulnerability, social isolation/loneliness and ageism. Findings – The elderly in the community are individuals who get their social interaction outside the home. As a result of the nearly three months of social isolation, they have experienced social disconnection and health problems, Originality/value – To the best of the author’s knowledge, this is the first attempt to give voice to the silenced group of elderly and share their thoughts and feelings during this difficult COVID-19 lockdown in Turkey. Keywords Elderly, COVID-19, Vulnerability, Social isolation, Ageism, Loneliness Paper type Viewpoint

ince the Chinese Government locked down the city of Wuhan in January 2020 on account of COVID-19, the disease caused by the corona virus has affected more S than 12.5 million people worldwide, with 560,000 confirmed deaths as of July 12, 2020 (World Health Organization, 2020). The disease continues to spread globally, causing more deaths daily. The outbreak has led to global disruption of daily life as schools and workplaces have shut down to slow the transmission. After Turkey announced its first COVID-19 case on March 10, 2020, the Turkish Government took strict precautions to minimize the spread of the virus through crowds. Thus, the government locked down all restaurants, cafe´s, shopping malls, stores and movie theaters. They cancelled sports events and social gatherings and banned weddings and funerals. They also closed prekindergarten through Grade 12 schools, along with universities, and moved from face-to-face to distance-learning platforms. A week later, on March 18, 2020, the Minister of Health, Dr Fahrettin Koca, announced the first COVID-19-related death in Turkey. The patient was an 89-year-old man who suffered from acute respiratory failure due to COVID-19. The deceased contracted the virus from someone who had contact with China. During the press conference, it was also noted that the number of elderly patients being admitted to intensive care units (ICU) was increasing. The World Health Organization (WHO) (2002) defines an elderly person as someone who is 65 years or older, and this definition is accepted by most countries.

DOI 10.1108/WWOP-07-2020-0037 VOL. 24 NO. 4 2020, pp. 303-311, © Emerald Publishing Limited, ISSN 1366-3666 j WORKING WITH OLDER PEOPLE j PAGE 303 At the beginning of March 2020, before Turkey had its first COVID-19 case, Italy and Spain had already been hit hard by the pandemic. The daily death tolls reached 1,000, and 90% of the deaths were people aged 70 years and older (Statista, 2020). The medical studies indicated that older individuals needed longer intubation and recovery time and had a lower chance of survival than younger patients (Carrieri et al.,2020). During the same period, WHO Regional Director for Europe Dr Hans Henri P. Kluge stated that older adults were at a significantly increased risk of severe disease following a COVID-19 infection. In April 2020, the top 30 countries that were most affected by the pandemic were the ones with the largest percentages of an elderly population in the world. These countries were all in Europe except for Japan. In total, 95% of these deaths occurred among citizens older than 60 years in age, and more than 50% of the deaths were among people aged 80 and older. Dr Kluge’s message was clear about “the need to protect, care and support older populations” (WHO, 2020). On March 21, the , Recep Tayyip Erdogan, imposed a partial curfew for citizens over the age of 65 and under the age of 20 and ordered them to stay at home as a measure to protect them against the COVID-19 outbreak. The age group 20 years and younger was also included in this partial curfew because studies (UK Research and Innovation, 2020) showed that children can play a role in transmitting COVID-19 to adults without showing any symptoms. It was called a “partial curfew” because citizens between the ages of 20 and 65 years were still allowed to go out. This curfew ended on June 10, having lasted 82 days.

Demographics of the elderly in Turkey Turkey has an elderly population of 7.2 million people, which equals 9.1% of the total population. According to Turkish Statistical Institute (TUIK) 2019 data, about 760,000 elderly individuals are currently in the workforce. Considering that older people play a less active role in the Turkish economy, reinforcing a curfew to ban the elderly from leaving their homes seemed an optimal solution to keep them safe while reducing the impact on the economy. According to the same TUIK data, 1,373,000 elderly residents live alone, and about 80% do not use the internet. During the curfew, the elderly who lived alone needed the most assistance of any group in buying their groceries, getting medications and withdrawing cash from the bank. This pandemic has brought significant emotional and financial burden to all of Turkish society, yet for the elderly, the emotional burden has been the most significant. I witnessed and lived through their struggles for three months as they felt excluded and battled with despair. I also observed their strong will to live yet concurrent acceptance of whatever their fate might be. In this reflective paper, I first share my own experiences during the COVID-19 pandemic as a caregiver for a group of elderly residents living in a small community. Then, I share their firsthand stories of how they felt about the pandemic and the policies enforced by the government that forced them to stay at home for three months without being able to see their loved ones during a time of crisis when they needed their support the most.

Living with the elderly during the COVID-19 pandemic I reside in a small community popular among retirees in Ankara, Turkey. In this community, there are 165 elderly citizens who typically spend their time taking strolls and gardening all year round. Most of the elderly have been living in this residential area for 30 years, since it was first built; therefore, they consider each other as family. I also grew up in this community, and five years ago, I bought a house here to live closer to my 74-year-old mother. I have known my elderly neighbors since my childhood and address them as auntie/uncle. Although they are over 70 years of age, they are independent and are

PAGE 304 j WORKING WITH OLDER PEOPLE j VOL. 24 NO. 4 2020 generally in good health with only minor health problems. Before the pandemic, they were busy with daily errands and activities and enjoyed life. My mother, with whom I have a very close relationship, is one of the healthy and very active residents. She does all her own housework and loves cooking. She meets with her friends in the community and spends time with them regularly. They love to drink traditional Turkish coffee together. She enjoys baking cookies and cakes and always shares them with her friends. Twice a week, I take her to the local farmer’s market, followed by a trip to the grocery store. It is our tradition to dine out once a week on Sundays with two of her friends and their daughters from our community. My mother is an extrovert who thrives on social interaction. Beyond this community, I work as a faculty member at one of the public universities in Ankara. I interact with hundreds of students in class and on campus. Until the first COVID- 19 case was announced in Turkey, none of us had heard of the terms “social distancing” or “self-quarantine.” Even after the first case was reported, we did not fully understand what these precautions meant, as we continued our normal routines (e.g. teaching classes and giving exams) without any interruptions. The first interruption was when our faculty administration informed us that an exchange student who was studying in Italy had returned to campus without quarantining and came in close contact with many. We were cautioned about this potential risk and infection. Soon after this, about a week later, the government made the decision to close all schools and universities in Turkey. Health officials warned us about how the virus spreads quickly and that older citizens were at immense risk. Given my position and my close contact with 600 students that I teach every week, I decided to self- isolate and self-quarantine at home to protect my mother and elderly neighbors. That is when I realized the pandemic was real and dangerous. On March 21, the government restricted citizens over 65 years old from leaving their homes. Those who violated the ban would have to pay a fine of 3,150 Turkish liras, which is approximately US$460. When my self-quarantine period was over, it was extremely important for me to visit my mother regularly again, as I am her caregiver. In addition, due to the ban, she could no longer see her friends. This isolation made her feel very lonely. I witnessed her slowly losing interest in doing things she loved. First, she stopped cooking. She started to take longer morning and afternoon naps. She complained how she could not sleep at night and always felt very tired. I tried to convince her to take short walks on her street but she could not, as her knees started to ache, and she was short of breath in five minutes. The longer the curfew lasted, the more I became worried. She lost track of time and frequently asked, “What day is it today?” I observed my mother closely every day, as her sharp memory started to decline to a state of dementia where she could not remember simple things like how to make a call on her phone. My mother, who had been a happy, lively person, was deteriorating into a depressed, non-active elderly woman. I tried to find ways for her to be more active but was not successful. The activities one can do at home for three months are limited; you soon run out of ideas. Eventually, I decided to invent a cooking class where my mother would be the chef, and I would be her apprentice. I asked her to help me to cook different foods from around the world. We would sit in front of the computer and search for new recipes. We tried to use the ingredients we had at home, as I avoided going to the supermarket. I know she forced herself to be interested because she loved me, but she was growing weary. She had become quick tempered and got angry with anything I said or did. I know she struggled, and this was how she expressed her emotions toward the fear of the pandemic. She felt upset and angry that COVID-19 was a threat to her, her friends and all the people her age. She felt as if she was imprisoned for a crime she did not commit. As she could not slap the corona virus, she yelled at me instead. I know she felt lonely, so I started to spend longer hours with her, sharing morning coffees and afternoon teas, chit-chatting about anything and everything. She slowly started to do her daily house chores again, one day at a time at her own pace.

VOL. 24 NO. 4 2020 j WORKING WITH OLDER PEOPLE j PAGE 305 After the curfew ended on June 10, my mother started to meet with her friends at the community park. Life had changed in the three months they were not able to see each other. With the pandemic still being a huge threat, they established a new set of guidelines among themselves. They no longer have their morning Turkish coffee at each other’s homes, they do not participate in any home visits, they always keep their social distance and use hand sanitizer, and they wear masks at the park. I would say they adjusted very quickly, better than most young adults I see in public. In addition to my mother, I spent three months of the pandemic in close contact with six other elderly neighbors, trying to care for and help them as much as I could with their needs. During the curfew, for these elderly, I was their only connection with the outside world. They asked me to order them books online as they did not know how to use the internet. I sometimes surprised them by bringing them morning bagels from the local bakery, and they referred to them as “the best bagel” they had ever tasted in their lives. Although it seemed like a simple act, it meant a lot to them, as they could not go to the bakery themselves. I would go shopping once a week, buy their groceries, and leave them on their front porch. I also went to their family physician on a regular basis to pick up their medicine. Every time I would take them their supplies, they asked, “How is the world outside?” and I answered, “Nothing to see, the world is sick.” It was sad because they knew that even if they could go outside, they might get infected and hospitalized. The lockdown ended on June 1, 2020 in Turkey for most people (e.g. work places went from remote to face-to-face, restaurants and hairdressers opened); however, for the elderly, it did not. After pressure from elderly citizens and health officials, the ban finally ended on June 10, 2020. As soon as the ban ended, I sat down with my six elderly neighbors and conducted semi-structured interviews. The interviews were recorded and completed in Turkish. Even though I was aware of their experiences, I wanted their stories to be heard and to give a voice to their silence during the pandemic, especially during the lockdown/ partial curfew. They expressed many thoughts and feelings about the pandemic and how it impacted their lives. I have identified three overarching themes based on what they have shared with me:

1. vulnerability;

2. social isolation/loneliness; and 3. ageism.

Vulnerability The younger generations have called the COVID-19 pandemic the “boomer remover” on social media, implying that the death of older people is not as important as the loss of life of younger people (Hoffower, 2020). The story of 72-year-old Italian priest Don Giuseppe Berardelli, who was infected with COVID-19 but gave up his ventilator to save the life of a younger person, was covered widely by local and international news media. Berardelli was called “a selfless man,” and as an early middle-aged woman, I found his act very noble. However, the question I ask myself is, “If I was 70 years old, how would I feel if society expected me to give up my life for a younger person?” The hashtag #video yukaldir in Turkish (#remove the video) emerged on social media after the curfew started for the elderly in Turkey. A number of young people started to post videos shaming and bashing old people because of their age and threatening to report them to the police. The videos were filmed when younger people would come across an older person walking outside. In the videos they would mock the older person and ask if they were in their late twenties or early thirties (www.youtube.com/watch?v=uKQy08Ejnlw). All these ageist discourses and devaluing of elderly people contributed to their feelings of worthlessness. They felt a sense of being a burden and that they had no value in society

PAGE 306 j WORKING WITH OLDER PEOPLE j VOL. 24 NO. 4 2020 (Brooke and Jackson, 2020). Witnessing all of this, I felt as if I was in the middle of a dystopic movie where there was a purge of older people; my elderly neighbors felt the same. Gurhan (pseudonym, as with all participants hereafter), a 76-year-old retired librarian, was my most energetic elderly neighbor, who never missed a chance to work out in nice sunny weather. However, Gurhan lost all his positive vibes and energy during the curfew. In his own words, “The pandemic made me feel a sense of emptiness. I lost my joy and passion for life. I have always been a person that loves learning new things, socializing and exploring. Now, I feel that there is nothing for me to live for. Young adults are struggling to adopt to the ‘new’ normal. I do not even have that option. I have to stay home and not get sick.” This older man’s world suddenly got smaller as the government widely publicized the #stayhomemessage. Many elderly were cut off from the face-to-face social interactions they used to have. Mehmet, 76, a retired professor of physics, had continued to teach part time at the university but had to quit his in-person classes when the university closed due to the pandemic. He was not asked to transition his face-to-face class to an online one because the university did want to add additional stress or burden, given that he had never taught an online class before. Mehmet was aware of the university’s good intention in wanting to keep him safe and healthy; however, he said, “I feel worthless. It feels like they have cut off one of my vital veins, and I am dying slowly.” The self-perceived uselessness of Mehmet and other elderly neighbors has impacted their well-being as they have been considered among the most vulnerable groups during the pandemic. Nilgun, a 73-year-old retired administrative assistant who is single and lives alone, can be described as one of the free-spirited elderly residents. She had never been dependent on anyone throughout her life, except during the curfew when she had to ask for help. Nilgun burst into tears when I asked her how she was, and she replied, “I am dependent on my niece, who works at a bank, to bring me food, medication, and other supplies. She barely has time after work but always helped me. I felt bad to ask for something but I had no choice. One day she forgot to buy potatoes that I put on my shopping list. I decided to walk to the supermarket that is right across from my house to get potatoes. The store manager did not let me in because of the age curfew. I felt hopeless. I feel that my younger friends and family saw me as a burden to them, as I had to ask for so many things during the curfew.” The elderly are among the most vulnerable groups during the pandemic, but being condemned for their age has had a very negative impact on them emotionally and mentally. The media has played a considerable role during the COVID-19 pandemic in accentuating the exclusion of and prejudice against older adults (Fraser et al., 2020). Unfortunately, the elderly have felt as if society is blaming them for the overburdened health system.

Social isolation/loneliness Human beings are social creatures, and our connection to each other is the reason we survive and thrive (National Institute on Aging, 2019). Research indicates that social isolation and loneliness are different conditions and do not always go together (Cacioppo and Cacioppo, 2014). Cacioppo and Cacioppo (2014) defined social isolation as the objective physical separation from other people (living alone), while loneliness is the subjective distressed feeling of being alone or separated. During the curfew, older citizens were not allowed to socialize with anyone. The hardest stipulation was avoiding social contact with their children and grandchildren. The elderly came to miss their families and friends so much that they started feeling lonely, isolated and secluded. In three months, my elderly neighbors’ health deteriorated as they started to feel depressed and show signs of anxiety. Segregation based on age reinforces the belief that

VOL. 24 NO. 4 2020 j WORKING WITH OLDER PEOPLE j PAGE 307 all older people are vulnerable and should be protected. Some societies see the elderly as less valuable, and they are often stereotyped as being unhealthy or always sick and having negative personal traits(Bettam, 2020). Nilgun stated, “I lived alone all my life, so I am used to being alone. I thought it would be easy for me as from time to time I have enjoyed being secluded. I was wrong! I realized that my social contact outside of home was important, and to order a simple cup of coffee at a cafe´ was socializing for me. The first two weeks were tolerable; I talked to my sisters and friends. However, soon I received fewer phone calls, and I did not want to call or talk to anybody. I had nothing to talk about.” Under ordinary circumstances, individuals have control over the number and quality of their interactions. However, the enforced social isolation resulting from COVID-19 caused loneliness. Kenan, 70, a retired mechanical engineer, lives with his wife. He is a very quiet person who loves to read and always borrows books from me. Kenan suffered the most during the curfew, as he stated, “I do not have many friends. I used to take a bus downtown twice a week. Public transportation is free for elderly people after morning and before evening rush hours. I have friends on the bus that I chat with. After the curfew started, I did not have anyone to talk to. My neighbors stayed away from me, not to get me sick. Not seeing anyone for three months was so hard that I questioned my insanity.” Self-isolation particularly affects the elderly whose social contact is outside the home, placing additional risk on their mental and physical health (Armitage and Nellums, 2020). Pakize, 71, a retired teacher who lives with her husband, loved going to the shopping mall to spend her day. She would go to a movie, have lunch, walk in the mall to burn off the extra calories, and head home in the afternoon. During the curfew, she said she started showing signs of dementia, and stated, “There is nothing to do at home all day. If that doesn’t drive you insane, I am not sure what can. I think I lost half of my remaining brain cells. I cannot even understand what I am watching on TV.” Most of the older residents in my community are individuals whose social contact is outside the home, such as in community centers, cafes and restaurants that they regularly go to and where they meet their friends. The three months of social isolation was a very long time that clearly demonstrated social disconnection among the elderly can cause health problems.

Ageism The COVID-19 pandemic changed how the elderly are perceived and treated. With the pandemic there has been a parallel outbreak of ageism (Ayalon et al.,2020). Ageism is defined by the WHO as “prejudice or discrimination on the grounds of a person’s age.” Many current portrayals of those over the age of 70 show them as being helpless, frail and unable to contribute to society. Negative stereotyping influences older people and can detrimentally impact their health (Levy, 2009). Gonul, 70, a retired postal worker, is more worried about her mother than anything else. Her mother is in a nursing home and she feels bad that she cannot bring her home during the pandemic. She sadly stated, “My mother is 93 years old and has been staying in a nursing home since January that I specifically chose which is close to my home. I visit her twice a week and take her favorite home-baked cookies and clean clothes. I know it gave her a feeling of home. After the pandemic outbreak, the government suspended all visits to nursing homes, especially to protect the elderly with special needs. I have not seen my mother for 4 months. I call her everyday but she does not understand why I do not visit. She is cognitively impaired, and she thinks I abandoned her as she cannot comprehend what a pandemic means. She cries every day. I cannot sleep at night thinking of her and how she must feel, so helpless and lonely. I feel like we are being punished for being old.” Gonul understands the nursing home’s enhanced precautions and protocols, as the elderly who reside in nursing homes are at great risk; yet, this does not make her feel at ease.

PAGE 308 j WORKING WITH OLDER PEOPLE j VOL. 24 NO. 4 2020 Pakize, who has two adult sons, complained about how her children have treated her like a child during the pandemic. She said, “When they were young our children needed our care. Now we need them! But I do not like it when they order me to do things. I am their mother, not their child.” Pakize has been overly sensitive toward the language use of her sons and other people. She discussed how suddenly everyone started to feel they have the right to treat her as incompetent due to her age. Nilgun reminds us that the elderly need to be active. She knows that the government is taking precautions to protect older people, but staying at home for so long comes with other problems. She stated, “I never left the house for three months. The first time the elderly were allowed to go outside, I could not walk more than 50 meters. I had to rest, so I sat down on a bench. Soon, all the benches were occupied by the elderly. We were like babies, learning to walk. To prevent falling down, we sat on a bench. For now, maybe we survived the COVID- 19, but we face health problems we never had before.” The social isolation aggravated the already deteriorating health of the oldest members of the community. Gurhan said, “After watching the news on TV, I was certain I was not going to survive this pandemic. Everyone was talking about the deaths of the older population. I felt like they have buried me alive.” The media widely covered data about elderly residents being potentially disadvantaged and imposed the idea that they are more expendable than people in other age groups. This resulted in older people thinking that they were going to die.

Discussion and conclusion The COVID-19 pandemic has impacted us individually and as a society in many different ways that have changed how we all live. Information identifying the elderly as a high-risk group in estimating mortality and morbidity during the COVID-19 pandemic across the globe has manifested in a widespread misperception that the elderly are less valuable and placed them in a confined zone of social exclusion. Such attempts to deal with the pandemic have resulted in widespread discriminatory attitudes toward the older population and in trauma for them. Labeling the elderly as a “highly vulnerable group,” disregarding cultural, social and contextual differences among individuals, has had a negative psychological and physical impact on their well-being that is likely to last for a long time (Rahman and Jahan, 2020). In the early stages of the pandemic, the focus was on the elderly and viewing them solely through the lens of their age. Early data from countries such as Italy and Spain suggested higher infection and mortality rates among older people. Beyond the threat to their lives, the pandemic put the elderly at greater risk of discrimination. Comments regarding the health of older residents were vicious and haunting. Ukraine’s former health minister stated that people over 65 years old were already “corpses,” and the lieutenant governor of Texas suggested that those over 70 years old should sacrifice themselves for the good of the economy. A UK newspaper journalist who wrote about the economic impact of the COVID- 19 pandemic implied that the death of older people could be beneficial by “culling elderly dependents” (Human Rights Watch, 2020). Older members of the global population have not been entirely without allies, however. United Nations Economic Commission for Europe (UNECE), Secretary-General Antonio Guterres stated, “First, no person, young or old, is expendable. Older people have the same rights to life and health as everyone else. Difficult decisions around life-saving medical care must respect the human rights and dignity of all” (UNECE, 2020). In Turkey, there are 425 nursing and retirement homes, and 27,000 residents continue to live there (Tokyay, 2020). The strict quarantine provisions do not allow for them to see their loved ones, and the uncertainty of the situation makes it harder for the elders to cope with their loneliness. There are very few nursing homes in Turkey compared to European

VOL. 24 NO. 4 2020 j WORKING WITH OLDER PEOPLE j PAGE 309 countries and the USA, as the elderly are usually taken care of at home by family members in Turkey (Bryza, 2020). This has helped to mitigate COVID-19’s mortality rate in care homes in Turkey, yet the challenges continue for all older residents there, both within care homes and those who live on their own or with family. If they want to travel within the country, there are new regulations in place. First, they have to stay at least a month at their travel destination, and second, they must get a code from the Ministry of Health’s mobile application. The application tracks COVID-19 cases (risk areas) in the area where the older resident travels and provides information about local health services. The curfew has not been lifted completely, as the elderly are only allowed to go out between the hours 10 a.m. and 8 p.m. Although the level of social isolation was a very difficult experience for those 65 years old and over in Turkey, and while restrictions due to the pandemic continue for these older citizens, the rigid strategy to protect them with a three-month curfew seems to have succeeded. The elderly here have escaped the worst of the pandemic, compared to the elderly of other countries, and deaths have never topped 127 people in a single day (The Economist, 2020). Nationwide, COVID-19 infection cases for all ages are on a decline. Turkish officials are implementing policies and taking precautions to adapt to a new normal, urging social distancing and mandating wearing a mask at all times. Only time will show how the world will overcome and recover from the virus. The world already looks significantly different today than it did yesterday.

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Further reading Statistica (2020), “Coronavirus (COVID-19) death rate in Italy as of June 22, 2020, by age group”, available at: www.statista.com/statistics/1106372/coronavirus-death-rate-by-age-group-italy/ (accessed 29 June 2020).

Corresponding author Ozgur Ates can be contacted at: [email protected]

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