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October 6, 2020
COVID-19 Child health
Joshua M. Sharfstein
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In my basement office, visible over my shoulder in my daily video calls, is a framed print of the famous World War I poster entitled, “The health of the child is the power of the nation.” The poster depicts children walking together up a hill, full of vitality and promise. Sponsored by the Children’s Bureau and the Women’s Committee of the Council of National Defense, the work of art by Francis Luis Mora celebrates the Children’s Year of April 1918 to April 1919. Even during a pandemic, the nation aimed to reduce infant mortality by one-third, establish maternal-child health programs in every state, and reduce child labor.
A century later, with the United States again facing a pandemic, 2020 is not a Children’s Year. As a disease, COVID-19 largely spares children, with rates of serious illness and death just a small fraction of those among middle-aged and older adults. However, in many other ways, COVID-19 is harming the health of millions of children in the United States. At the root of this dichotomy is not biology; it is the nation’s priorities.
The United States has long lagged behind other countries in social policies and health outcomes for children. Compared to other wealthy nations, the country offers some of the least generous benefits for workers’ paid leave, child care support, and flexible work schedules. More than 50 nations have lower infant mortality rates. A study comparing the United States to 19 other countries counted 600,000 excess child deaths over the past 50 years.
COVID-19 has exploited these weaknesses. Food insecurity is now its own epidemic, with one in five mothers with children younger than 12 reporting that their children are going hungry, and Black and Hispanic households experiencing rates of hunger three to four times higher than white households. Physicians are reporting higher rates of severe child abuse, even as reports to social service agencies decline. One in seven children are experiencing worsening mental health since the pandemic began.
And, then there is school. Thousands of public schools remain closed, with persistent demographic divides in access to technology needed for distance learning. It is anticipated that some children may fall behind by as much as one year or more. In a vicious cycle, keeping kids out of school slows the economic recovery by keeping parents home; it also widens the gender gap in earnings. No wonder more than one in four parents reports worsening mental health.
Evidence from other nations indicates that schools can open with a high degree of safety when two conditions are met: community transmissions are low and adequate precautions are taken. The United States is failing on both counts. Where other countries have focused on reducing transmission to the point where schools can open with relatively low risk, local politics favors opening seemingly every business first, even those, such as bars, that are known to be hot spots of transmission. In Maryland, for example, the Governor recently followed up a call for schools to reopen quickly with a decision to reopen movie theaters and entertainment venues, and to permit indoor gatherings of up to 100 people, in contradiction to his own pandemic roadmap.
Meanwhile, the federal government is providing little support to help schools put in place physical improvements, additional staffing, transportation changes, testing, and other key elements of a successful response. Instead, thousands of teachers face furloughs or layoffs because of budget cuts at the state level. Legislation to facilitate the reopening of schools, as well as extend food assistance and unemployment benefits to those in need, has passed the House of Representatives but not the Senate.
There is one glaring exception to the dismal set of options facing many children: private schools. Though public schools have yet to receive resources to facilitate in-person learning, many private schools have hired more staff and moved forward. The tragedy is not just that educational and social divides are widening before our eyes. It is that so little of the potential power of empowered parents has been directed to creating opportunities for all.
In May, Danielle Dooley and colleagues wrote about their frustration as pediatricians over the sacrifices by low-income children for the greater good. Not only are so many children missing school and going hungry, but also so few policymakers are prioritizing urgent action to help them before the consequences for society are severe and long-lasting. “To recognize and respect this sacrifice,” they wrote, “the US should make a commitment to provide [children] with the opportunities they have long deserved.”
Such a commitment must go beyond allocating temporary funds to patch gaps in distance learning and address other immediate social needs. A national campaign to reduce child poverty is urgently needed. As outlined by a committee of the National Academies of Sciences, Engineering, and Medicine, this effort would involve expansions in food assistance, the earned income tax credit, housing assistance, and the child care tax credit. Also needed are focused investments to address the longstanding impact of racism. One example is the critical need for equity in school infrastructure, instruction, and extra-curricular activities.
Yes, this project would be ambitious. But that did not stop the United States in the midst of pandemic a century ago. Back then, the United States recognized that at stake was more than just the health of children; it was the power of the nation. It’s time for another Children’s Year, long overdue.
Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.
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