I started writing this article before the COVID-19 pandemic. At the time, I wondered how best to frame the concepts of prevention and equity so they would make sense to the reader, given they can be hard to understand or enact. I have always been impressed by the writing of epidemiologist and physician Professor Sandro Galea at the Boston University School of Public Health. He eloquently writes about the power of public health and prevention such as: “Our health is not defined by things like seeing doctors or taking medicines or getting in our 5,000 steps a day. Rather, it’s defined by the full spectrum of our life circumstances, from the families we come from to the neighbourhoods where we live to the people we see and the choices we make.”
Then along came COVID-19 and the world now understands the power of public health in saving lives. We have seen play out in real time Rose’s prevention paradox1 – the idea that interventions which may or may not be needed for the individual can actually make the most difference for the population. Previously, we have provided examples such as seatbelts, but now we can point to COVID-19 – when entire countries of individuals were prepared to lock down to protect the health of the population.
So how can we apply these very real lessons to ensure that we have a better and more equitable Australia for children post-pandemic? Every year nearly 300,000 children are born in Australia, and we know that about 11 per cent will start school developmentally vulnerable (i.e., they will likely struggle to succeed in school) on two or more domains of development based on the three-yearly Australian Early Development Census. Importantly, there will be three times more developmentally vulnerable children in poorer areas than wealthier areas; these data haven’t changed substantially for the last 10 years. Yet we know that investing in early childhood, especially the first 1000 days, pays off with prevention of adverse adult health and social outcomes, and substantial benefits to society and human capital. Right now, Australia spends $15.2b each year on crisis services for children and young people experiencing serious issues (e.g., services for children in out-of-home care). This represents a missed opportunity to make smart investments in early intervention, to improve the lives of children and young people by preventing or reducing the severity of these issues, and reducing pressure on government budgets and increasing savings in the long term.2
… prevention becomes even more important because we do know how disasters and their related interventions impact children.
To understand the implications of COVID-19 for children, it’s important to note that children on the whole will not be directly impacted by the virus. Rather, there will be indirect effects of the public health interventions. In this context, prevention becomes even more important because we do know how disasters and their related interventions impact children. Research from previous epidemics, pandemics and disasters has shown the following (noting that impacts are often found many years after the initial event):
- Physical health: Possible effects of nationwide school closures and home confinement can include: being physically less active, having longer screen time, and eating less healthy diets.3
- Mental health: Responses to pandemics are unique in that responses discourage gathering of victims, instead requiring separation and quarantine. School closures and physical distancing strategies can cause confusion, frustration, boredom, symptoms of post-traumatic stress, disruption to children’s routines, lack of in-person contact with peers and teachers, increased family stress levels, and lack of personal space in the home.3-6
- Academic performance: The social disruption caused by natural disasters and pandemics can impact children’s academic performance. Expected gains in academic scores can be reduced; importantly, the same cognitive skills needed for learning are known to be impacted by early trauma experience.7
- Vulnerable populations: Public health interventions such as school closures during a pandemic have the potential to create adverse outcomes that disproportionately affect vulnerable populations; this can include compromised access to school meal programs, having to rely on self-care in the home while parents work, and disrupted education.8
COVID-19…the great ‘accelerator’.
COVID-19 has been called the great “accelerator”. So, using existing systems and policies, how can we correct for the inequities that will undoubtedly emerge from the necessary public health interventions? And how can we close the existing inequity gap to ensure that kids of the COVID generation can be healthier than generations past?
I propose a dual approach of system change and policy drivers to enact a rapid but robust response to prevent adverse and inequitable outcomes for children:
- System change: Get the data and metrics needed to inform, drive and evaluate an accelerated system response
- Utilise existing cohorts, surveillance data and new cohorts (such as GenV, the whole of Victorian birth cohort starting in 2021) to understand the differential impacts of COVID-19 on subgroups of children.
- Build system metrics that are anchored to existing services for young children around the triple bottom line of quantity (are there enough), quality (are they good – an especially important point for addressing inequity), and participation (who actually comes).
- Policy drivers: Purposefully build the protective factors across the social, health and education ecosystem to enable sustained and equitable outcomes
- Social: Directly address the threat to child wellbeing.
- e.g., Non-conditional cash transfer – boost to families with children younger than five years, noting the adverse impact of socioeconomic disadvantage.
- e.g., Non-conditional cash transfer – boost to families with children younger than five years, noting the adverse impact of socioeconomic disadvantage.
- Social: Directly address the threat to child wellbeing.
- Health: Child-centred and equitable access to health care.
- e.g., Mental health – build in prevention and early intervention surge from proportionate delivery if existing universal and primary care.
- e.g., Telehealth – develop innovative practices that ensure high quality care particularly (but not exclusively) targeting regional areas.
- Education: Address the potential learning crisis made worse by remote learning policies.
- e.g., Schools to purposefully and robustly address the learning equity gap from the early years.
- e.g., Schools to collect data that can help address mental health problems in partnership with local health services.
Suzanna Arundhati Roy powerfully writes: “Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.”
When we look back on 2020, will it be remembered as the year we took a leap into a new world of equity and hope, or will we see Australia squander the opportunity that COVID-19 presents for the children now and the adults of the future?
REFERENCES
1. Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J. 1981;282:1847-1851.
2. Teager W, Fox S, Stafford N. How Australia can invest in children and return more: A new look at the $15b cost of late action. Australia: Early Intervention Foundation, The Front Project and CoLab at the Telethon Kids Insitute;2019.
3. Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. The Lancet. 2020;395(10228):945-947.
4. Sprang G, Silman M. Posttraumatic stress disorder in parents and youth after health-related disasters. Disaster medicine and public health preparedness. 2013;7(1):105-110.
5. Stevenson E, Barrios L, Cordell R, et al. Pandemic influenza planning: addressing the needs of children. American journal of public health. 2009;99 Suppl 2:S255-260.
6. Galea S, Merchant RM, Lurie N. The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. JAMA Internal Medicine. 2020.
7. Gibbs L, Nursey J, Cook J, et al. Delayed disaster impacts on academic performance of primary school children. Child Development. 2019;90(4):1402-1412.
8. Berkman BE. Mitigating pandemic influenza: the ethics of implementing a school closure policy. Journal of public health management and practice : JPHMP. 2008;14(4):372-378.
