No one knows exactly how many U.S. nursing home residents died due to COVID, since the data is unreliable. But in her piercing new book, American Eldercide: How It Happened, How to Prevent It, Margaret Morganroth Gullette estimates that it was at least 152,000 during just the first year of the coronavirus outbreak.

As heartbreaking as that number is, Gullette maintains that some—if not many—of those deaths didn’t need to happen. “Almost everything that seemed irrevocable could have been different,” she writes.

The better nursing homes kept COVID out, Gullette, an anti-ageism activist and resident scholar at Brandeis University’s Women’s Studies Research Center, tells Fortune.

In her book, which has been nominated for a Pulitzer and a National Book Award, she writes that 1,950 of the nation’s 15,400 nursing homes had no COVID deaths.

What went wrong in the other 13,450?

How COVID spread in many nursing homes

While some deaths were likely unavoidable, Gullette, who previously wrote Ending Ageism, or How Not to Shoot Old People, places blame for many others at the feet of President Donald Trump, the Centers for Medicare and Medicaid Services (CMS), nursing homes and state governments.

Gullette uses the word eldercide to describe what she calls “the abandonment of this concentrated and confined group of older adults to exposure and death, on a mass scale, by those responsible for their welfare.”

She is incensed that some people think the COVID nursing home deaths were inevitable because they believe “the Old die.”

In reality, Gullette says, “many of the people in nursing homes live very long lives; if they hadn’t died of COVID, they could have had another 10 or 15 years.”

Some COVID nursing home deaths were people who came to the facilities for short-term rehab stays after hospital discharges.

“If you’re sent to a skilled nursing facility after an operation or pneumonia or need to learn to walk again, you’re treated just like everybody else in a COVID emergency,” Gullette says. “If there’s no PPE (personal protective equipment) there, you don’t get the PPE. If there’s understaffing, you suffer from everything that anybody else there would suffer from.”

This type of rehab nursing home care is paid by Medicare, which covers about 30% of nursing home residents. Medicaid, the federal/state program generally for low-income people, pays for most of the others.

Which nursing homes protected residents best

Gullette found that nonprofit nursing homes were less likely to have COVID deaths than for-profit ones. In the 300 nonprofit Green House facilities (groups of small houses with single rooms), the median death rate per 100 residents was statistically zero, Gullette writes.

Some of the safer facilities separated patients on COVID-only floors or buildings through a practice called co-horting.

Gullette cites the small Baptist Aged Home in Baltimore, run by the Reverend Dr. Derrick DeWitt Sr. as an example of the types of nursing homes that did well in protecting residents during the pandemic.

Its low-income residents were mostly African American, many with chronic conditions. None became infected with COVID during its surge or even as late as January 2021, when the vaccine became available.

“The director instantly locked down” the nursing home, Gullette says. He also quickly brought in more PPE gloves, masks and gowns and had food brought to the residents’ rooms, making COVID spread less likely.

“He also gave the aides lunch so they didn’t have to go out,” says Gullette. Experts believe some residents at other nursing homes contracted COVID from staff rotaing between facilities to make a living. “Dewitt paid his aides well enough that they didn’t need a second job,” says Gullette.

There are no figures for the total number of COVID deaths among nursing home staff, but Gullette found that roughly one staffer died from the virus per 100 to 150 resident deaths in December 2020 and January 2021.

A lack of PPE

Strong safety precautions in nursing homes were unusual during the height of COVID, Gullette writes.

Nursing homes, she says, didn’t get enough PPE when the virus first arrived. “The National Strategic Stockpile had been depleted,” Gullette says.

Hospitals, she writes, often got PPE before nursing homes did.

Her book cites Dr. Mark Lachs, director of geriatrics at New York-Presbyterian Healthcare System, writing about the disparity: “Nursing homes should have the best PPE and access to testing and infection control experts. During the pandemic, they had the worst.”

In March 2020, the U.S. government reduced nursing home inspections, making it harder to know which facilities were unsafe. “That would be precisely when the inspectors were most needed,” says Gullette.

Lessons learned?

Have nursing homes and the federal and state governments learned lessons to better protect residents in the next pandemic?

“There has been change, but I would say it’s probably not enough,” says Gullette.

She is pleased that the Biden administration proposed minimum staffing standards for nursing homes, which could improve the quality of care. Some Republicans, however, are pushing to prevent the standards from taking effect.

Gullette is also glad that a few states have taken steps to bolster their stockpiles.

But, she says, “a lot of what was wrong at nursing homes was going on before COVID and is going on now.”

As a recent Modern Healthcare series on nursing homes noted, one in three skilled nursing facilities in America has been cited by federal or state authorities for abuse, neglect or mistreatment. In 2023, Senate Special Committee on Aging Chair Bob Casey (D-Pa.) said that oversight of America’s nursing homes “is in crisis.”

A call for a COVID memorial

In her book, Gullette proposes a Washington, D.C. memorial to all the nursing home residents who died due to COVID. She envisions a museum and library—“with all their names, and maybe their stories and their words.”

But she doesn’t think we’ll ever see it.

“It seems to me that it’s perfectly clear the pandemic began in nursing homes. It could have been stopped there had attention been paid,” Gullette says.

“The residents are a special responsibility of the public health system and should be treated as precious,” she adds. “Instead, they were abandoned.”

Thousands of America’s vulnerable elderly people died during COVID. This change could save lives next time