A bitter legacy of poverty and violence

The health of South Africa’s children was already under threat long before the advent of Covid-19 – with nearly 60% living in poverty, 30% without access to water on site and 18% in overcrowded households. It is therefore not surprising that lower respiratory tract infections and acute diarrhoea are two of the leading causes of under-five mortality, and that 49% of child hospital deaths are associated with malnutrition.

Violence against women and children is widespread, with 99% of children in the Birth-to-Twenty study having either experienced or witnessed violence, and over 40% reporting multiple incidents of violence in their homes, schools and communities.

Covid-19, lockdown and recession – a perfect storm

These pre-existing patterns of adversity, combined with a fragile and fractured health care system, have left children extremely vulnerable when exposed to shocks such as Covid-19. The associated lockdown and economic recession are causing significant collateral damage, as rising unemployment and financial hardship fuel an increase in domestic violence and compromise children’s nutrition, mental health and access to health care services.

Adult care should not come at the cost of child health

While international data suggests that children are less vulnerable to Covid-19 than adults, experience less severe symptoms and are less likely to be spreaders of the virus, it is not yet clear how the virus will impact on children in South Africa given the high proportion whose immune systems are compromised by exposure to HIV (25%)[1] [2] [3] [4] [5], stunting (27%) and TB.

There is also a real danger that the focus on adult Covid care will come at the cost of childrens’ health, survival and development. Already there are emerging reports from healthcare workers of physical and human resources being diverted from paediatric services to support adult care, at a point when paediatric services are thinly stretched by the annual surge in diarrhoea and pneumonia admissions – with an average of 50,000 children younger than five admitted to hospitals with pneumonia every year, and a further 37,000 admissions for diarrhoea.

In addition, there are reports of routine maternal and child health services being withdrawn or downscaled; caregivers being turned away from healthcare facilities; and an increase in late presentations and severe complications due to delays in care-seeking behaviour (driven by concerns about the risks of Covid-19 infection).

Globally, the disruption of essential maternal and child health services, coupled with growing food insecurity, is threatening to erode nearly a decade of progress, with John Hopkins University’s Bloomberg School of Public Health anticipating an additional 1.2 million young child deaths globally in just six months.

For example, the disruption of immunisation services, even for a short period, increases the risk of potential outbreaks of vaccine-preventable diseases such as measles, which will place an additional burden on a health system already strained by the Covid-19 response. The disruption of growth-monitoring means we are unable to identify and support an increasing number of children at risk of moderate or severe acute malnutrition. Disruption of routine care for children with disabilities and long term health conditions may lead to contractures, secondary disabilities and/or life-threatening delays in accessing care.

Access to healthcare services for acute care and to prevent ill health are only one component of care required to ensure that children not only survive, but also thrive. Children, especially the youngest, thrive in an environment of relationships – the most important being their relationship with their parents and caregivers. It is these affectionate and responsive caregiving relationships that enable access to preventive and curative health care, adequate nutrition, protection from harm and opportunities to play and learn. These elements of nurturing care are essential for the health and wellbeing and development of children, and it is our obligation as health professionals to support both children and their families during these challenging times.

A call to prioritise child health

Given children’s acute vulnerability in the Covid-19 pandemic, the UN Secretary-General António Guterres has called on states to prioritise children and uphold childrens’ right to healthcare services in their Covid-19 response plans (as outlined in the United Nations Committee on the Rights of the Child’s General Comment on the Right to Health, and the World Health Organisation’s recommendations for the care and protection of children in disaster settings).

We, therefore, call on the National Department of Health to maintain routine maternal and child health services, respond proactively to emerging challenges, and actively support children infected or directly affected by Covid-19.

Maintain and strengthen routine essential services

Given the fragility of children in the current socioeconomic context, all routine maternal and child health services should be viewed as essential and must be maintained. This should include:

• Routine antenatal and postnatal care for pregnant women, mothers and infants.
• Support for breastfeeding, skin-to-skin contact and kangaroo mother care.
• Acute care for common childhood illnesses such as diarrhoea and pneumonia.
• Alternative strategies to ensure the safe delivery of contraceptives, antiretroviral therapy and other chronic medication, and
• Ongoing access to therapy and treatment for children with disabilities and long term health conditions.

Respond proactively to emerging challenges

Proactive measures need to be put in place to address the anticipated increase in malnutrition, abuse and vaccine-preventable diseases – by ensuring that every point of contact with the healthcare system is used as an opportunity to:

• Identify and catch up immunisations missed during lockdown.
• Monitor growth and support children at risk of malnutrition, and
• screen for child abuse and neglect, and refer children in need of care and protection to social services.

These efforts should be accompanied by a public education campaign to provide reassurance that it is safe to visit health facilities, encourage access to routine services, and ensure that mothers and caregivers of children are aware of the danger signs for Covid-19, severe acute malnutrition and other childhood illnesses and know when to seek care.

Support children and families affected by Covid-19

Finally, it is essential to put measures in place to support children and families directly infected or affected by Covid-19, from initial testing and diagnosis, through quarantine and isolation, to hospital admission, intensive care and reintegration into schools and communities. This should include:

• identifying children in need of care and support by asking routine questions about dependent children and childcare arrangements when adults are admitted to hospital.
• avoiding the separation of children and caregivers wherever possible when children are admitted to hospital and/or using mobile technologies to enable children to access care and support from family members.
• providing child-friendly information about Covid-19 – its symptoms, treatment, and prognosis – and psychosocial support to help children and families cope with the fear, anxiety, stigma, grief and loss.

We therefore note with concern that there have been significant delays in developing a coordinated response to the care of children. The initial clinical guidelines were developed with adults in mind, and care for children and neonates has only recently been incorporated into the fourth draft of the National Clinical Guidelines. These guidelines address some, but not all, of the child-centred measures outlined above, and there are significant variations in the way in which the guidelines have been interpreted and implemented across provinces and facilities.

A clear implementation strategy and monitoring and accountability mechanism are urgently needed. District and clinical managers, hospital management teams, clinicians and other frontline health workers need to be actively engaged and supported in order to translate national guidance into concrete actions in health facilities and to make contingency plans as the epidemic progresses. Taking such an approach will prevent poor decision-making, such as redirecting paediatric staff and beds to adult services at this early stage of the epidemic, when it is still unclear what the impact of Covid-19 will be on children in our context.

South Africa has made significant progress in reducing child mortality and has committed to a global agenda to ensure that all children survive and thrive. Delayed, uncoordinated and narrow responses to the comprehensive care of children amidst this pandemic will derail these efforts – with children living in the poorest households carrying the heaviest price.

In the words of Gabriela Mistral, an award-winning Chilean poet:

The child’s name is Today
The child cannot wait.
Right now is the time the child’s
bones are being formed,
blood is being made,
senses are being developed.
To the child we cannot answer
‘tomorrow’
The child’s name is Today. DM/MC

Lori Lake, Matsie Mashishi, Neil McKerrow, Zolile Mlisana, Jenny Nash, Wiedaad Slemming, Haroon Saloojee and Chantell Witten are all members of the Child Health Priorities Association, a child health advocacy group, providing for interaction of child health professionals from a variety of fields (such as health, social development and law). The CPHA holds an annual conference on Child Health Priorities in December every year.