The COVID-19 Pandemic and Health Disparities Among Children: A Q&A with Dr. Rachel Johnson Thornton

Dr. Rachel J. Thornton, associate professor of pediatrics at the Johns Hopkins School of Medicine, on how the coronavirus pandemic is affecting children and worsening health disparities throughout the United States.

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As the coronavirus pandemic stretches into the fall, COVID-19 raises particular challenges for children. For groups of children already experiencing health disparities, the effects of the virus have been particularly severe. To understand how the coronavirus pandemic is affecting children and worsening health disparities throughout the United States, we turned to Dr. Rachel J. Thornton, Associate Professor of Pediatrics at the Johns Hopkins School of Medicine.

What are health disparities?

Health equity is achieved when everyone has a just and fair opportunity to be as healthy as possible. We measure society’s progress towards achieving health equity by tracking meaningful differences in health status that are indicative of the ongoing health effects of injustice or disadvantage for certain groups in our society. Termed health disparities, these meaningful differences in health are the measure or metrics we use to quantify the progress or lack of progress toward achieving health equity. Health professionals use these metrics to shine a light on these meaningful or unjust differences in health outcomes that adversely affect marginalized groups.

How do health disparities vary between adults and children?

In general, patterns of health disparities are durable across the lifespan. We see acute disparities in children across health conditions including asthma and obesity that are often based on racial/ethnic and socioeconomic status. In general, the patterns of disparate health outcomes in marginalized groups of children are similar to the patterns we see with adults – across a variety of conditions.

But one concern for children, especially, are vaccination rates. During the pandemic, there have been significant reductions, according to CDC data, in vaccination rates among children eligible for Medicaid – that’s a disparate health impact.

How are health disparities influencing the pandemic’s impact on children?

We’ve seen a lot already and we need to think broadly about not just infections from COVID-19, but also about how our responses to COVID-19 are disparately impacting different groups. For instance, what are the impacts of a move from in-person to online schooling or reducing access to public benefits such as food stamps, energy assistance or unemployment benefits? What is the impact of substantial reductions in the economic viability of non-essential businesses on children and their families? These policies have the potential to disproportionately affect vulnerable families’ abilities to meet their children’s needs. And the impacts are distributed in inequitable ways throughout our society, where people who have more resources are less likely to experience severe hardship from physical distancing measures or lockdowns. For others, these measures could intensify food or housing insecurity, especially with regards to closing schools and limiting the meals they traditionally provide to food insecure children.

There have been a lot of discussions among pediatricians and educators about access to education during the pandemic. There’s the well-established, existing phenomenon documenting disparate learning loss for low-income and racial-ethnic minority children during the summer time (i.e., “summer slide”), and many are rightly concerned that we’ll see these gaps exacerbated between advantaged and disadvantaged children due to the pandemic. This could also worsen due to inequitable access to technology, which can complicate a child’s ability to take advantage of remote learning. The reason this is a health issue is because educational attainment is a strong indicator of socio-economic status later in life and can have significant impacts on one’s health and financial wellbeing as an adult.

Another concern directly tied to the closing of schools is child nutrition. For food insecure children, the shutdown has made it hard to weigh the appropriateness and feasibility of closing schools for a certain period of time. For families that rely on school nutrition programs for free or reduced price meals for their children, the closures have made them considerably more vulnerable to poor nutrition and hunger than they were before. One positive response to school closure was an added, one-time EBT – or food stamps – benefit in the federal CARES Act. This benefit was to offset the cost of these meals for families in districts that were eligible for a free and reduced lunch. I saw the look on parents’ faces when they learned about the extra benefit – they were thinking about how to stretch that money as much as possible. It’s clear this made a difference, but it wasn’t enough.

There are also ongoing concerns about school closures leading to a rise in child maltreatment, as schools are places where teachers and aides are trained to keep an eye on how students are doing physically and emotionally and are required to report cases of suspected abuse. There are ongoing concerns about disparities tied to mental health and trauma from the pandemic, but it’s too early to say what the long-term impact of these factors on child health and equity will be.

Why might these disparities be occurring among different demographic groups of children?

In truth, I’m not sure the patterns of disparities we’re seeing now are that much different from disparities before COVID, but the pandemic is intensifying them and bringing them to the fore of public consciousness. Across the board, being a member of a marginalized group or low-income population carries risks for child health, and the full impact of COVID-19 on the health and well-being of the most vulnerable children will continue to emerge over time. Before the pandemic, in 2019, the National Academy of Sciences issued a report that identified poverty as a fundamental cause of poor health for children in the U.S. We also know that racism is a fundamental threat to child health that the American Academy of Pediatrics statement released in 2019 laid bare. Thus, there are several forces at play during the pandemic that continue to put certain groups of children at greatest risk of harm and poor health. As an example, our inability to return safely to normal day-to-day life is disproportionately affecting families and children that were already disadvantaged economically.

On top of that, even before the pandemic close to 20% of children in the U.S. were poor, and their parents tend to have jobs that cannot accommodate working from home. This creates myriad challenges for low-income working parents. When they go into work, they are more likely to be exposed to the virus, which intersects with other disparities such as limited access to affordable childcare when schools are closed, limited access to broadband or technology for virtual learning, food insecurity, housing insecurity, and limited access to transportation. Together these conditions intersect such that Black, immigrant, and indigenous children are negatively impacted by both the virus and the consequences of the economic shut down in their communities.

These repercussions from poverty have also expanded to near-poor families that potentially had just enough resources before the pandemic to avoid food insecurity or housing insecurity but are now in dire straits from the adverse economic effects that continue in the face of the ongoing pandemic. Relief initiatives have largely not met the urgent need for housing, economic aid and healthcare during this pandemic. The inaction has consequences for increased disease transmission, but even bigger than that, the financial impacts of the pandemic are having outsized, disparately negative impacts on the health of those who were already vulnerable and struggling before COVID-19.

How can communities address COVID-related disparities for children?

There are a lot of ways for communities to respond. Something I always try to emphasize in my work is that pediatricians have a key role to play as a resource and support for families. In many instances, medical providers and other community workers are aware of available resources like food banks, energy assistance or nutritional assistance, so I would encourage families in these positions to let their medical professionals know and to ask for assistance and not hold it as a source of shame.

On the community level, we need to avoid scenarios where vulnerable families are getting evicted or where they feel they have no choice but to continue to go to work despite concerns about symptoms of, or exposure to, the virus. I think communities have a role in raising up voices of compassion and advocating for compassionate policies from their governments to those in need due to the pandemic and the unprecedented economic hardship it has inflicted. That might mean letting local, state or federal lawmakers know about needs for housing security or adequate nutrition in your community. This includes things like advocating for programs to prevent worsening homelessness, evictions or hunger in your community and expressing your beliefs about the resources communities need during the pandemic to be able to care for all members in need. By ensuring stable housing and access to material resources, communities can begin to address the disparate outcomes that will linger long after COVID-19. That’s how communities can give voice and help people facing dire straits through no fault of their own. There’s a lot of pain and concern, especially in communities that feel they don’t have a strong voice or platform, and we need to encourage them to make their voices heard by the people who represent them. This includes ensuring the parents and caregivers of children are encouraged to vote and to be counted in the Census and to have their voices heard. It’s about ensuring that families can do the very best by their children and that, during this crisis, everyone has the resources to make that happen.