When COVID-19 hit the Westervier nursing home—a residential care center in the Belgian city of Bruges—it struck with swift severity.

“We had residents talking in the living room in the morning. Then they became short of breath. Then drowsy. And in the evening they were gone. It went very fast,” said Dirk Snauwaert, director of Westervier.

Snauwaert’s facility saw 25 deaths in the first two weeks of April. By June, 38 of his 118 residents had died of COVID-19, or about a third of the facility’s population. Workers carted the deceased’s belongings—artwork, books, leather chairs, and boxes of knickknacks—to an underground garage where they sat in empty parking spaces once reserved for visitors.

Already health officials had placed Belgium’s nursing homes on lockdown, prohibiting visitors, including family, hoping to stop the spread. But indoors the virus spread rapidly, brought in initially, many believe, through caregivers or visitors returning from skiing vacations in Italy.

Belgium, long known as the country through which all of Europe’s wars march, has played an outsize role in the continent’s battle with the coronavirus. Spain, Italy, and the United Kingdom gained attention for their extensive outbreaks; Belgium—with land mass roughly equivalent to Maryland but twice that state’s population—has held the world’s highest recorded mortality rate.

Confirmed coronavirus cases in Belgium surpassed 60,000 in mid-June, with more than 9,600 deaths—for a chart-topping mortality rate of 85 deaths per 100,000 persons, according to Johns Hopkins University. That contrasts with a mortality rate in the United Kingdom (which leads Europe in total cases) of 64 per 100,000 and with a U.S. mortality rate of 37 per 100,000. Belgium’s reported caseload has tracked Michigan’s—its number of deaths is nearly 4,000 higher.

The numbers are bad enough that eight European countries did not reciprocate when Belgium reopened its borders to Europe. A further 12 required Belgians to quarantine before visiting. The restrictions came as a stunning rebuke for Belgians who’ve endured a strict lockdown since March and have prided themselves for a transparent accounting of deaths, including suspected cases of COVID-19.

Any reckoning leads to the nation’s nursing homes, where at least 53 percent—and in some areas perhaps 65 percent—of COVID-19 deaths occur. An average 42 percent of U.S. deaths are taking place in nursing homes.

As in the United States, Belgian nursing homes come in all sizes and combine private rooms with communal living spaces where the elderly often live as family. Some are state supported, others commercial ventures or nonprofits. Many are run by Catholic charities.

From the start, nursing homes faced extraordinary challenges with inadequate preparation. Protective gear went to hospitals, including some confiscated from nursing homes. After the H1N1 flu epidemic passed, Health Minister Maggie De Block had ordered in 2017 the nation’s stockpile of surgical masks destroyed, leaving a critical shortage.

“It was war. I had to send my people to the front. But we had no bullets,” said Snauwaert.

As COVID-19 cases began to spike in March, nursing homes received no tests. Masks were available only by prescription. Caregivers rewashed protective gowns meant for one-time use, or simply didn’t use them.

From the beginning, top government officials and the Belgian Society for Geriatrics and Gerontology recommended against hospitalizing those from nursing homes, including for other conditions. They feared ICU beds would run out, though Belgium never exceeded 60 percent of its intensive-care capacity. Lacking the trained staff or equipment (like ventilators) to treat severe respiratory distress, some nursing homes were left without options but to watch their residents die.

Snauwaert told investigators with the Dutch-language newspaper De Standaard that nursing homes in Belgium have been “step-mothered” for years. “Our government has forgotten elderly people,” he said when I reached him by phone in Bruges. Snauwaert said he and many of his staff members worked seven days a week from March through May, treating residents—accustomed to frequent daily contact with one another—in isolation and battling critical supply shortages. His own facility ran out of oxygen.

“People thought: Those residential care centers, they are already death houses, if they [die] there a little earlier, then so be it,” he said.

With COVID-19, said Léopold Vanbellingen, research officer at the European Institute of Bioethics, “the main problem we have had is with politicians who chose to sacrifice nursing home residents for this crisis.”

Belgians have been living under a caretaker government for more than a year. Unable to form a governing coalition, the parliamentary system has been at a standstill, the Dutch-speaking north and French-speaking south more divided than usual. Competing health ministry officials and overlapping federal and regional governments all add up to a mismanaged response to the coronavirus crisis.

“Officials considered that those who get COVID-19—or anything else during the crisis, including a heart attack—are not a priority for hospital care. They are not admitted,” said Vanbellingen. “A lot have died alone in nursing homes not necessarily because it made no sense to admit them, but because experts chose that it would be necessary not to admit them.”

The institute found some hospitals refusing to admit all advanced-age patients, but particularly those living in nursing or retirement homes. One nursing home, featured on national television news, became so overwhelmed that doctors sent to help found feces in the hallway and dehydrated residents drinking from dirty cups.

De Standaard newspaper launched its investigation after registering the scale of what happened, said Ruud Goossens, one of two journalists who visited nursing home facilities and spoke to more than 40 doctors, nurses, home directors, and government officials. In Flanders alone, the journalists discovered that more than 3,000 of a total 4,800 COVID-19 victims were people who lived in residential care facilities, Goossens said.

At Atrium, a 44-bed nursing home in Kraainem, Goossens spoke to director Kathy Huybrechts. Huybrechts slept on a mattress atop her desk through the crisis once her head nurse and 13 others became ill with the coronavirus. Short-staffed and overwhelmed, Huybrechts summoned ambulances to take sick residents. Twice, medics arrived but refused to accept them once they learned they were COVID-19 cases. Between April and May, 14 of 44 Atrium residents died.

“Huybrechts had problems that everyone in the sector had,” Goossens told me by email. “And they felt abandoned.”

LACK OF PREPAREDNESS for a pandemic has dogged the coronavirus response on both sides of the Atlantic, costing lives predominantly among the elderly but also furthering the spread under the guise of containment. In April New York Gov. Andrew Cuomo and state health commissioner Howard Zucker made it all but mandatory for hospitals to discharge nursing home patients with COVID-19 and return them to their facilities as a way to free up beds.

In a state order issued March 25, Cuomo also barred testing of those being placed or returned to nursing homes. In the weeks following, the coronavirus killed more than 6,000 nursing home residents in New York.

At a Troy, N.Y., nursing home, an investigation by ProPublica showed how the virus multiplied among residents and nonelderly caregivers. Hospitals transferred to the home two residents with COVID-19 on April 22. Within one month, 18 residents had died. Another 58 had been infected, while at least half of the nursing home’s 100 workers tested positive for the virus.

Other states followed that protocol with similar results, ProPublica found: Michigan lost 5 percent of roughly 38,000 nursing home residents, and New Jersey lost 12 percent of more than 43,000 residents. In contrast Florida, which barred hospital transfers back to nursing homes and tested 80 percent of nursing home residents, by mid-June had 1.6 percent of 73,000 nursing home residents die.

Columbia University epidemiologist Charles Branas said the “reverse triage” strategy may well have increased New York’s death toll: “If you introduce 4,500 people sick with a potentially lethal disease into a vulnerable and notoriously imperfectly monitored population,” he told ProPublica, “people are apt to die.”

As in the United States, nursing homes in Belgium instituted strict no-visitation policies that made it hard to impossible for family members to ensure loved ones received adequate care. Unlike the United States, Belgium has arguably the most permissive laws in the world on euthanasia, or physician-assisted suicide.

With the pandemic, watchdog groups worry overstretched facilities could resort to euthanizing sick residents. At nursing homes in Wallonia, relatives report receiving consent forms prescribing reduced treatment for residents, particularly those with dementia. The form, seen by WORLD, asks relatives to circle “yes” or “no” to indicate whether the resident should receive hydration, oxygen, and medicine like antibiotics.

In facilities with high COVID-19 rates, palliative sedation has become a form of treatment, according to Vanbellingen. Some resort to morphine and other sedatives to treat the “air hunger” that’s a panic-inducing effect of severe COVID-19. Without proper dosing, it can lead to a quick death.

Vanbellingen stressed that at this time he sees “no direct link between euthanasia and COVID-19.” But more study remains as the virus caseload subsides.

On June 15 the Westervier residential care center in Bruges, with no reported cases of the virus, reopened to visitors. “When there is an outbreak again, we can organize more quickly,” said Snauwaert, the director.

The rate of infection in Belgium dropped drastically after its mid-April peak, but the number of deaths has continued to rise. Residents and caregivers are “stressed and tired,” Snauwaert said. “We have conflicts over what happened, some sharp, and we need silence and relief from the care load before we can go back as we were.”

Westervier got its start in a Catholic congregation in 1688 among “spinsters,” a group of women who worked at the spinning wheel. They served their neighbors visiting and caring for the sick and aged in their homes. Gradually they created enduring group housing for the elderly, and in 1991 the church established a nonprofit that runs multiple care facilities in West Flanders. “In the turbulent waters of history, these women were able to adapt their service to sick and aging people again and again, depending on the needs of their own time,” reads the nonprofit’s website.

Snauwaert hopes his people can adapt again: “The people we have lost are people we know well. But also it’s important to look to the future and hope we can do things better than before.”

How Belgians count

Some European countries are just beginning to count their nursing home residents who have died due to COVID-19. Belgium early on counted not only confirmed but suspected COVID-19 deaths. For a time officials said that’s why the Belgium mortality rate stuck stubbornly at the top of the charts. Now months into the crisis, official deaths can be compared with the excess mortality of Europe’s worst-hit countries to give a more accurate picture. Using that measure, Belgium’s official deaths come in at 87 percent of excess deaths—a good score, but one that means its high mortality rate is also reasonably accurate. What’s clear for now: Nearly all official data tends to undercount COVID-19 deaths.