It’s time to put children first – from response to recovery
While children have mostly been spared from severe infection, our preoccupation with adult COVID-care has meant that children’s needs were overlooked and they were left to bear the brunt of the COVID-19 pandemic. As we approach the peak of the third wave in the Western Cape, it is time to stop and count the costs, and to put children at the heart of our response and recovery plans.
Over the past year, global efforts to flatten the curve have caused significant collateral damage: deepening levels of poverty and hunger, intensifying pressures and the threat of violence within the home, and limiting families and children’s access to schools, health care, early childhood development and other support services – with children likely to carry the costs for years to come.
This series of advocacy briefs developed by the Children’s Institute, University of Cape Town, in collaboration with the Children’s Hospital Trust and the Michael & Susan Dell Foundation, therefore calls for greater prioritisation of children in South Africa’s COVID-19 response and recovery plans.
The briefs document the impact of the pandemic on children and children’s services, and identify opportunities to strengthen systems, improve outcomes and better support children in future waves and crises. They draw on data from the Western Cape – as even in this relatively well-resourced province, children’s needs were initially overlooked.
Protect children from immediate shock and long-term harm
Series editor, Lori Lake of the Children’s Institute, University of Cape Town, describes how children are particularly vulnerable to both the immediate shock and enduring impacts of COVID-19: “This is especially the case during sensitive and rapid periods of development such as the first 1,000 days of life[1] and adolescence when exposure to hunger, violence or toxic stress can cause long-term and irreparable harm to children’s immune systems, their developing brains and education and employment prospects.”
Co-editor, Professor Maylene Shung-King of the School of Public Health, UCT, highlights how: “Shocks such as climate change and COVID-19 also tend to intensify existing inequalities: For a privileged few, the pandemic simply meant a change in lifestyle, but for the majority of South Africans, the pandemic has been catastrophic with families facing unemployment, hunger, violence and an uncertain future.”
For example, children in the Western Cape were relatively better off than children in other provinces prior to the pandemic, with nine out of 10 children having access to health care and basic services and living in households where someone was employed in 2018. Yet their relative advantage masks significant inequalities – one in four children lived below the poverty line, one in ten children in food-insecure households, and one in six children in informal housing where overcrowding and poor water and sanitation increased their vulnerability to infection. And COVID-19 has cut deep along these fault lines in our society.
So, what do we know about the impact of the COVID-19 pandemic on children?
In the first year of the pandemic there were over 284 000 cases of COVID-19 in the Western Cape and just over 12 300 of these cases were children. 1 500 children were admitted to hospital and 59 children died of COVID-19.
According to Professor Chris Scott of the Department of Paediatrics and Child Health, UCT: “The initial health systems response to COVID-19 care focused on adults who accounted for over 95% of cases in the Western Cape. Children’s needs were side-lined, resources were diverted from paediatrics to adult COVID-19 care, and concerns around infection prompted the separation of infants and children from much needed family support. Yet, overtime, child health specialists succeeded in advocating for a more child-centred approach to contact tracing and the care of children in hospital.”
While children accounted for only 4% of cases in the province and 0.5% of the deaths, thousands more children have been affected by the illness and death of family members. Over one million children around the world are estimated to have lost a primary caregiver from March 2020 to April 2021. Therefore, we also need to put systems in place to identify children in need of care and protection when adults are admitted into hospital.
Dr Jaco Murray, a paediatrian at Paarl Hospital, described how: “The focus on adult COVID care, and efforts to prevent infection, led to a significant drop in the coverage of essential child health services, with a 23% decline in young children’s visits to primary health care services. This has led to gaps in screening and treating children for HIV, TB and acute malnutrition and will have a profound impact on children’s health and development for years to come.”
As hospitals prepared for the first wave of COVID-19, paediatric and adolescent beds were re-allocated to adult COVID-care, elective surgeries were cancelled, and many children with disabilities were unable to access care. Over the course of the year, hospital admissions for diarrhoea and pneumonia decreased, (perhaps due to mask-wearing, hand-washing and social distancing), yet the in-hospital mortality rate increased, raising concerns that parents’ fears of contracting COVID-19 were leading to life-threatening delays in seeking medical care.
Concerted efforts by child health practitioners and community health workers helped ensure that some of these services were fully restored – with measles immunization recovering to 95% (a 5% increase on coverage in 2019). However, it will require time, ongoing advocacy and proactive decision-making to address the significant and potentially life-threatening backlogs in elective surgeries.
Professor Michael Hendricks of the Department of Paediatrics and Child Health, UCT describes how: “Rising unemployment and food prices increased pressure on poor households with 47% of households running out of food during hard lockdown. Despite families’ efforts to shield their children, child hunger has remained high with one in seven households reporting that a child went hungry in April 2021. At the same time the disruption of routine health services made it harder to identify and support children at risk of .”
The introduction of the caregiver allowance and top up grants in May 2020 offered some protection for children, but hunger increased again when these were withdrawn in October 2020. In addition, Dr Katharine Hall, Senior Researcher at the Children’s Institute, UCT, warns that: “The decrease in the real value of the Child Support Grant (valued at R460 a month or R15 a day in April 2021) is likely to intensify child hunger in the coming months, raising concerns about a potential rise in severe acute malnutrition – especially in Gauteng and KwaZulu-Natal where recent protests have disrupted food supply chains”.
Early in the COVID-19 pandemic, child rights activists raised concerns about how rising unemployment, food insecurity and the stresses of lockdown would increase the risk of violence and injury in the home. Carla Brown, Head of the Social Work Department at Red Cross War Memorial Children’s Hospital, describes how: “Despite these projections, there was a 10% decrease in children admitted to the trauma unit for non-accidental injuries – such as sexual abuse, physical abuse and gun violence. This was primarily driven by a sharp 50% decrease at the time of hard lockdown and the alcohol ban, yet cases returned to pre-COVID levels by September 2020 when lockdown measures eased.”
Professor Shanaaz Mathews, Director of the Children’s Institute, UCT, cautions that: “These figures do not necessarily represent a real decline in violence and maltreatment. Instead, they are more likely to reflect the difficulties women and children faced in trying to access health care and other support services during hard lockdown. It is therefore essential to put proactive measures in place to identify and support women and children who experience interpersonal violence during pandemics and similar crises.”
There have been very few studies on how the pandemic has impacted on children’s mental health, yet we know from previous humanitarian crises, that COVID-19 is likely to trigger a dramatic increase in depression, anxiety and post-traumatic stress disorder in both children and their caregivers. According to Professor Mark Tomlinson, Director of the Institute of Lifelong Health Research, University of Stellenbosch: “Women have been particularly hard hit by unemployment, food insecurity, domestic violence and an increased burden of childcare, and these additional pressures compromise their own mental health and that of their children. In addition, most children have been exposed to some form of loss – loss of school, loss of friends, or the loss of loved ones – and they need support to cope with grief.”
Specialised child and adolescent mental health services remain extremely limited in South Africa. Greater efforts are therefore needed to build the capacity of families and frontline workers in schools, ECD programmes and health care services to help children cope with loss and adversity.
Early childhood development programmes
Early childhood development programmes perform an invaluable service to society and have the potential to support young children and their families in times of crisis – by enabling caregivers to seek employment, and ensuring that young children receive safe care, good nutrition, and early learning. Yet, Lizette Berry, Senior Researcher at the Children’s Institute, UCT argues that even prior to COVID-19, the ECD sector in South Africa was fragile and underfunded: “The mandatory closure of ECD programmes in 2020 intensified existing challenges. Prolonged lockdown, limited state support and the withdrawal of the ECD subsidy in most provinces, led to the permanent closure of many ECD programmes and significant job losses. And this will cause not only immediate and long-term harm to the health, nutrition and education of young children.”
Education and schools as nodes of care and support
The opening and closing of schools during the COVID-19 pandemic has been highly contested as the education department seeks to minimise the disruption to children’s education while keeping children, educators and the broader school community as safe as possible.
Fewer than 1% of learners (1 200) contracted COVID-19 in the Western Cape in 2020, and 3 900 learners required quarantine, mainly from community-acquired infections. Yet, despite these relatively small numbers, widespread fears prevailed about learner and educator safety, resulting in repeated school closures.
Dr Patti Silbert, Director of the Schools Improvement Initiative at UCT, describes how: “The school closures have had a devastating impact on education, with the majority of primary school children losing close to a full year of learning and an estimated 750 000 learners dropping out of school. Closures also prevented children from accessing an important source of nutrition, health care and psychosocial support, with over 9 million learners losing out on a daily school meal during lockdown.”
Seven principles to guide a child-centred response to COVID-19
The following seven principles are essential ingredients in ensuring that put children first and build back better from COVID-19.
- No regression:
The Gauteng High Court has affirmed that even in an economic crisis, government may only introduce regressive measures as a last resort, after considering all other options and ensuring that children are the last to be affected. - Maintain essential services:
The state must fulfil its immediate obligations to protect and sustain essential services for children and uphold children’s rights to basic education, health care, child protection services, ECD programmes, and social assistance. - Leave no one behind:
We need to ensure that our efforts to control COVID-19 do not further intensify existing patterns of inequality and discrimination. We need to put additional supports in place for children with disabilities, adolescents in need of mental health and reproductive health services, and the many children in need of poverty relief and nutrition support. This includes expanding social protection and increasing the value of social grants to better protect children from rising unemployment, poverty and hunger. - Keep an eye on the child:
In addition, real-time surveillance and strong referral systems are needed to identify and support children in need of food, care and protection, and psychosocial support. - Build partnerships:
This will require partnership, collaboration and collective action – across different communities, sectors and disciplines, and between government, business and civil society –in order to harness the insights, expertise and resources needed to address children’s complex needs. - Listen to children and take them seriously
Children are not simply passive recipients of care and protection. They also have the potential to play an active role in informing a child-centred response to the pandemic. For it is only when we make time to include children and take them seriously that we can design interventions that really speak to children’s needs and concerns. - Provide strong leadership
Ultimately, protecting children in times of crisis will require strong leadership and advocacy for children in our schools, health care system, child protection services and at the highest level of government to ensure that children’s best interests are proactively addressed and prioritised in South Africa’s response and recovery plans.
What is good for children and adolescents is ultimately what is good for societies and putting children at the centre of our efforts to build back fairer and better after the pandemic will be key.
The full set of advocacy briefs are available on the Children’s Institute website: www.ci.uct.ac.za
[1] From conception to a child’s second birthday
