As we go into the third month of a national lockdown, more and more South Africans face economic instability. This comes at a cost for many children, as food security, physical and mental health as well as general well-being are being threatened. 

The United Nations reported that children could be among the biggest victims during the Covid-19 pandemic. While in South Africa already more than 60% of children lived below the poverty line in 2017, there could be an increase in extreme poverty. An increase in poverty and economic hardship will lead to higher child mortality rates and malnutrition. Besides that, lockdown measures and social isolation come with an increased risk of children suffering or witnessing abuse and violence, even more in settings with crowded and unsanitary conditions, according to the UN. Furthermore, as reported by Unicef, dependence on online learning platforms increases the risk of online sexual exploitation and makes children more vulnerable to online predators. Lastly, the closure of schools is affecting the educational and mental development of learners. 

For many children in South Africa, schools provide not only education, but also nutritional and social support. There is a concern that prolonged school closures will increase inequalities, worsen the learning crisis and subject the most vulnerable children to an enhanced risk of exploitation. Other crises have shown that the longer disadvantaged children are away from school, the lower the chances that they will return. Especially girls are at risk during school closures, as seen during the Ebola crises in West Africa, where the number of teenage pregnancies and the rate of sexual exploitation increased, as reported by Unesco. 

In 2019, 28.18% of South Africa’s population were under the age of 15. Furthermore, another 17.24% were between the ages 15 and 24 years. Only 5.81% were older than 65. This shows that almost half of the population in South Africa is at a very low risk for Covid-19, while the lockdown has affected them most, due to school closures. 

The general measures, which were very strict and applied as precautionary measures to all South African citizens,  were required to strengthen the health system. They should now be gradually diversified according to a number of parameters such as age, health status and needs. 

Many of the above-mentioned consequences of school closures can either be reversed or minimised by reopening the schools as soon as possible and by investing in our children. 

Risk of Covid-19 for children

The risk of Covid-19 infection appears to be very small for children below 12 years old, both in case rate and prognosis. In two recently published systematic literature reviews from Liguoro et al and Ludvigsson, it appeared that children make up less than 5% of all Covid-19 cases and that the disease tends to be milder in children than in adults, with deaths being extremely rare among children.

The risks of Covid-19 infection and transmission from physical contact between children at school are much smaller than the risks from other respiratory viruses for which such measures are not taken.

The direct risks of Covid-19 to children are very limited, while the negative consequences from the requirement to limit physical contact between children are demonstrated to be large, pervasive and long-lasting. Correct policies should take these long-term consequences into account and put the interests of children first (Unesco). 

The impact of social interactions on overall development is greatest in younger children. Children are, therefore, at risk of becoming the greatest victims of the current restrictions, while they themselves have the lowest direct risk of infection and complications.

Physical contact between children promotes development and reduces stress. Children who grow up in vulnerable social living conditions are often in a state where they are subject to toxic stress. This has a dramatic impact on the development of their brain on the one hand, but also on their physical health, now and in the long term. Extensive research has been carried out in recent decades. One of the most important factors to make children feel safe again is social and physical contact. Many children have long been in “toxic” stress for the past few months. The longer they are forbidden this physical and social contact, the greater the consequences for their development, now and later. Contact in play between children, holding and being comforted when children are scared or sad, and touch from warmth and friendship are essential elements that reduce stress and redevelop children, as seen by Shonkoff et al. 

Allowing physical contact at school and beyond may not seriously affect Covid-19 in society. Although the mild course of Covid-19 does not exclude transmission by children as asymptomatic carriers, there is a large and growing body of evidence showing that children are rarely the cause of infection. In other words, they appear not to be the driving force behind the epidemic (“Children are not COVID-19 super spreaders: time to go back to school”) .

Recently published scientific material from Jing et al showed that the odds of infection among children (aged below 20 years) was 0.26 times of that among the elderly (older than 60 years).

Furthermore, Denmark did not see an increase in Covid-19 cases after schools for children up to 12 years old were reopened more than five weeks ago. 

The impact of social isolation

Social contacts are crucial for the social development of the child and contacts with peers are essential for developing social and ethical standards. Cacioppo and Cacioppo showed that social isolation leads to decreased activity and delayed development of the “social network” in the brain regions (the striatum, temporoparietal junction) associated with social learning, empathy and social togetherness. Social isolation also has a negative impact on the immune system, making the child less able to fight infections.

Furthermore, there has been evidence of an increase in traumatic experiences (as a result of physical ones or emotional abuse) and non-accidental injury in children due to isolation during the Covid-19 pandemic. 

Unesco has called for schools to be reopened as soon as possible in the interests of the mental well-being and development of children. Excluding children from school constitutes a violation of their rights, which cannot be justified on the basis of real risks.

First, the learning capacity for certain skills (eg, language development) has an optimal window, after which a developmental delay can no longer be made up. A 2019 study from Australia showed that children in post-disaster communities, due to closures of schools as well as other stressors, had lower academic achievements up to four years after the natural disaster, compromising their future academic trajectories and life opportunities.

Second, the school is not just a place to learn. Schools also play a crucial role in social protection, support for physical and emotional health of the child and prevention of child abuse and are vital for children from vulnerable families. Besides, going to school provides structure and helps to maintain a healthy day/night rhythm. 

Younger children are not yet able to make an adequate and realistic assessment of risks. Normalisation of their living environment is necessary to prevent them from developing anxiety disorders due to an overestimation of the perceived risk. Research from a previous SARS epidemic in Asia showed that 30% of long-term isolated children had post-traumatic stress disorder. 

Recommendations

By not reopening schools as soon as possible for all children, we create a vulnerable society by impacting children’s physical and mental health in a negative way, as well as their prospects for a good future by taking away the fundamental right to education, which is essential for healthy growth and development. Currently, there is no justification for a prolonged closure of schools as all available research has shown that children are not a risk group in the Covid-19 pandemic. 

Furthermore, as research so far has shown that children under the age of 12 years are not the driving force of this pandemic, they should be able to go back to school in a “normal” way, allowing interaction between children, which is so important for healthy development.

Children should follow hygiene measures and maintain distance from the school staff, but can also play and learn with each other without restrictions, possibly only in their own class. 

Older children (above the age of 12) have similar transmission rates to adults. However, this age group is still not a risk group, but they might transmit the virus to other family members who are at risk of developing complications. Therefore, it is recommended that in this age group, social distancing where possible, hand hygiene and the wearing of face-masks is implemented in the classroom. In this age group, children can be educated about preventive measures. 

If a child has underlying conditions, parents/caregivers should discuss with their healthcare provider and decide whether their child goes to school. High-risk individuals in the family are an argument for not doing this, or for taking additional measures (for example, using a face-mask at school). 

Teachers are essential workers and should be addressed as such. They have an incredible responsibility for the healthy development of the children in South Africa and we should not underestimate the difficulty of their job, dealing with children who are coming back to school after months of social isolation, and potentially suffering from poor physical and mental health.

Teachers in a (documented) risk group should decide, in a well-informed but autonomous manner, whether to teach or not.

School employees outside the risk groups can apply hygiene measures themselves: hand hygiene, face masks and keeping a distance where possible.

Funds need to be prioritised for the preparation of schools, including hiring extra teachers/staff, and providing soap and running water in every school.

There will be outbreaks of Covid-19 in some of the schools, which could then be (partially) closed temporarily, with cases traced and quarantined until it is safe to reopen again. 

All nutritional support programmes should be restarted as soon as possible. Malnutrition rates have increased since the lockdown and undernourishment on its own can lead to a higher vulnerability to disease. Poor nutritional status was shown to be a negative prognostic factor for Covid-19. 

Conclusion

If we don’t prioritise the reopening of schools for all ages nationwide and invest in the necessary measures to open in a responsible way, this will come at a great cost to the children in South Africa at many levels. Education is a fundamental right, and based on current research there are no valid reasons to keep schools closed. Furthermore, depending on age and health status, preventive measures for infection should be implemented. DM