One Belgian doctor described nursing homes in his country as a scene of “carnage” in the first wave of the coronavirus pandemic, with fatalities inside the institutions pushing Belgium to a worst-in-the-world death toll. Afterward, policymakers vowed to fortify the care homes to protect against a potential new surge.

Yet deep into a second wave, the virus is racing through nursing homes once more, and advocates say some of the same broad mistakes are cementing Belgium’s status as a country where reported coronavirus deaths per capita are off the charts.

Nursing home personnel lament that they are being sidelined again, while policymakers focus on protecting the hospital system from being overwhelmed. But as in the spring, more nursing home residents are dying than any other segment of society.

“The same as in the first wave, nursing homes are not being taken so seriously and not getting the priority,” said Mit Philips, an official in the Belgian office of Doctors Without Borders — which usually operates in poor societies beset by conflict and crisis but was called in to advise Belgian nursing homes through the pandemic.

Belgium has reported more coronavirus deaths per capita this year than any other nation. Over the past week, it averaged 17.4 daily deaths per million residents — that’s five times worse than the United States, which averaged 3.5 deaths per million.

Belgian policymakers say that comparisons can be misleading, that their calculations are more complete than in other countries. But they also acknowledge they have paid a heavy toll, especially in homes for the elderly.

More than 2,000 Belgian nursing home residents have died since Sept. 1, accounting for 43 percent of coronavirus deaths in that period. Spring was worse: Sixty-four percent of all coronavirus deaths were nursing home residents, most of whom never got access to a hospital. Homes for the elderly no longer have to scour dive shops for scuba tanks after running out of extra oxygen. Nursing homes are isolating sick patients more quickly. But some experts offer another, grim explanation for the improved numbers: There are fewer residents left to die.

“We learned from the first wave, but it was not enough,” said Dominique Lamy, the coordinating doctor for three nursing homes in Mons, in southwestern Belgium.

“During summer, we prepared all the material, all the protocols, all the procedures,” Lamy said. But the government underestimated how rapidly a resurgence of the virus among younger people would make its way into homes for the elderly, he said.

The surge among Belgian nursing home residents illustrates the sometimes deadly consequences of not having enough tests to monitor outbreaks.

When Belgian testing centers were overwhelmed in mid-October, the government decided that only people displaying symptoms could get tested — a policy that wasn’t reversed until this week. Nursing home administrators and doctors say that blackout period allowed the virus to speed into their facilities through asymptomatic carriers and cut off their ability to act when it might have made the biggest difference.

“The decision in October to test only people with symptoms made no sense. It was like turning off the smoke detector when you know there is a high fire hazard,” said Vincent Fredericq, the secretary general of the Belgian federation of nursing homes.

Hospitals were granted an exception to avoid outbreaks among their workers. Nursing homes weren’t, even though many caregivers are in close physical contact with residents for long periods every day.

During the first wave, Belgian nursing homes were quick to ban visits from residents’ families and friends. They paid less attention to staffers, who turned out to be a major vector of the disease.

“We closed the drawbridge of the castle, leaving the rear gates open,” Yves Van Laethem, a spokesman for the official government response to the pandemic, said in testimony to Belgium’s Parliament in September. “We banned visits, but we didn’t realize that there was asymptomatic transmission.”

During the second wave, nursing homes wanted to be far more vigilant about their personnel, who had little choice but to come and go in the middle of an explosion of cases. But since the nursing homes had little access to testing, they could only sit, cross their fingers and try hard to take care of the residents who got sick.

“We are getting into the winter period, a number of a residents are getting fevers, and it is crucial for us to understand whether they have covid-19. Or is it something else?” said Michel Hanset, the coordinating doctor of La Cambre, one of the largest nursing homes in Brussels.

As surging cases have put stress on the medical system, nursing home directors and doctors have once again found themselves in frustrating conversations with hospital administrators, having to justify why sick residents should get hospital care.

“The hospitals ask us: ‘What is the prospects for the patient? Is the patient very active, or is the patient in bed with cognitive problems?’ ” said Lamy, the nursing home doctor in Mons. “The choice is difficult because all humans need help and the same treatment.”

In the spring, Belgian policymakers bragged about never allowing the occupancy of intensive care beds to rise higher than 60 percent, even though entire hallways of elderly nursing home residents were dying without access to advanced treatment. Policymakers have denied there was ever any formal policy to keep nursing home residents out of hospitals, which would be illegal. But 78 percent of nursing home residents died outside of hospitals in the first wave.

Lamy affirmed that despite the difficult phone calls, there’s more collaboration between hospitals and nursing homes this time.

“Now, we’re working together,” he said.

And now, 72 percent of nursing home residents’ deaths are taking place outside hospitals.

To an extent, Belgium’s difficulties are a testament to the challenge of trying to wall off any one part of society while cases rage in other quarters. And in that, Belgium is hardly alone. Swedish leaders, who have pursued a light-touch approach to lockdowns for much of the pandemic, declared they would concentrate extra efforts on vulnerable populations, then admitted they failed after a wave of death in nursing homes. More people have died in French nursing homes this month than in the previous five months combined. In the United States, nursing home deaths have surged every time the virus itself has surged, making health-care workers fear for the coming weeks as covid-19 races through the country.

“When the pressure of the virus builds up in general society, it will eventually, with a few weeks’ delay, affect your most vulnerable populations,” said Steven Van Gucht, the head of viral diseases at the Belgian public health agency.

Some experts fear that even though the virus appears to be subsiding in Belgium, it will continue to burn inside nursing homes.

“In the nursing homes, once the virus is there, you can give a lot of attention, but you cannot put people in lockdown,” given that nursing home residents cannot be isolated from caregivers, said Emmanuel André, a virologist who was part of a team advising Belgian policymakers on their pandemic response during the first wave this spring.

“That implies that the progression of the outbreak will be slower, but it will still continue. This phenomenon made our wave last longer, and this may also happen now,” he said.

Birnbaum reported from Riga, Latvia. Quentin Ariès in Brussels contributed to this report.