Health Inequities and Risk for COVID-19 in Children
by Janelle Menard, PhD, MPH, and Elizabeth B. Pathak, PhD, MSPH
The rapid spread of COVID-19 has capsized social and economic systems on a global scale, and no one is entirely spared from its reach. Much media attention has been given to the fact that children often present with much milder symptoms and rarely become seriously ill with COVID-19 when compared to all other age groups. The recent article in JPHMP, “COVID-19 in Children in the United States: Intensive Care Admissions, Estimated Total Infected, and Projected Numbers of Severe Pediatric Cases in 2020” (Pathak, Salemi, et al.), discusses SARS-CoV-2 penetrance in pediatric populations and possible scenarios for severe and critical cases. While the reasons for low rates of severe pediatric cases are not yet completely understood, a small proportion of them progress to severe or critical disease. Taken together, these observations have the danger of creating a sense of complacency in public perception and discourse about COVID-19 in children. In societies with large populations, even a small proportion of severe and critical pediatric cases can quickly overwhelm health care systems that are already strained.
Knowledge gained from past epidemics and humanitarian crises is instructive. Infection risk and disease trajectories are largely determined by the social, economic and geopolitical contexts in which they occur. Pandemics expose the fault lines of inequality in societies as evidenced by economic and spatial patterns of unequal distribution of risk and disease. Consequently, the built and social environments in which families and children live will greatly influence exposure risks during this pandemic. For poor and marginalized children, the confluence of SARS-CoV-2 susceptibility, communicability, and socioeconomic disadvantage will very likely produce poorer health outcomes.
Children’s health is inextricably linked to the health and well-being of their families on whom they depend. As this pandemic unfolds in the US, patterns are emerging that indicate families and their children already are experiencing the effects of inequality on their health. For example, sharp differences exist in the ability to maintain a household income while under stay-at-home orders. Parents and guardians of children who have less education and limited options for employment are more likely to hold jobs in labor market sectors that preclude the ability to work from home and comply with public health orders. Some examples include jobs in service, construction, retail, and agriculture industries, gig economy jobs and informal economy work. Low-wage employment often lacks job security, prevents workers from building up savings, and offers few if any benefits, such as paid sick leave or paid vacation time.
In spite of existing social assistance programs, socioeconomic factors affect lower income families’ abilities to obtain timely medical care. Insufficient income increases food insecurity and limits safe, clean housing options. Nationally, the majority of families living in subsidized housing are located in densely populated urban areas where conditions support the high transmission of SARS-CoV-2. Thus, children who live in urban, communal subsidized housing will likely be more vulnerable to infection.
Certain rural settings also pose increased risks for children from vulnerable populations such as farmworkers. Careful consideration of the built and social environments of farmworker families is essential for controlling the transmission of SARS-CoV-2. States with some of the largest populations (eg, California, Texas, Florida) also have robust agricultural industries in which the majority of the field labor force consists of seasonal and migratory farmworkers. Migratory farmworkers are itinerant and follow a labor circuit dependent on crop harvest needs, whereas seasonal farmworkers usually reside in one place. Thus, regular geographic migration to follow harvest work may play a role in sustaining SARS-CoV-2 transmission.
Additional challenges to assessing and controlling COVID-19 in farmworker populations are linguistic and structural. The vast majority of all farmworkers are from Mexico. Limited English proficiency may be a barrier to readily accessing public health information during this pandemic. Because a significant proportion of this labor force is undocumented, participation in SARS-CoV-2 screening and seeking timely medical care when necessary may be hindered due to fear of immigration officials and lack of trust in the new, temporary health settings that are arising to accommodate widespread testing and COVID-19 treatment.
Roughly half of farmworkers are parents with children, who often accompany parents in arduous field labor. Federal child labor protections allow for children as young as 10 to 12 years old to work in agriculture with parental consent for any amount of time outside of regular school hours. When growers base earnings on piece rate wages, children’s labor can be essential to a family’s household income. In addition to the inherent health risks of agricultural field labor, poverty limits most migrant farmworker families’ housing options to substandard housing either rented in the private housing sector or on growers’ lands. Collectively, these conditions render children in all farmworker families more vulnerable to poor health in general and increased risk during this pandemic.
The success of mitigating the transmission of SARS-CoV-2 now is largely predicated upon large-scale behavior change. The understanding of SARS-CoV-2 infection risk in children, and the potential for both somatic and psychological sequelae, must be rooted in the social and built environment contexts in which risk, health and illness arise and are sustained. Poorer and marginalized communities historically bear a disproportionate burden of disease in pandemics. When assessing children during this pandemic, health practitioners should consider how poverty may affect pediatric risk of infection and the potential for serious illness. Special consideration also should be given to populations such as children of migrant and seasonal farmworker families, who face unique challenges in preventing transmission of SARS-CoV-2. Clinical and public health practitioners would benefit immensely from working in partnership with national networks, and state, local and faith-based community organizations and community health clinics that have an established trust and history of serving farmworker and other high-risk populations.
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Dr. Janelle Menard is an applied medical anthropologist with expertise in mixed research methods and community‐based participatory research strategies in social science and public health. She has conducted ethnographic fieldwork and public health research in the French Caribbean and among Latin American and Caribbean immigrants in the U.S. South. Her research has informed the development of interventions that address health inequity in underserved populations. Her fieldwork experience and personal relationships with immigrant families in Florida inform her advocacy for interdisciplinary research and community partnerships to address health disparities.
Dr. Elizabeth B. Pathak is an epidemiologist who has who has spent 30 years conducting research on geographic, socioeconomic, and racial disparities in health. She is a passionate advocate for methodologically rigorous scholarship which seeks to uncover the power relations that perpetuate socioeconomic and health inequalities. She has published numerous scientific papers and seven books and monographs. She has held positions in state and federal government, and served on the faculties of West Virginia University and the University of South Florida. Beth has lived and worked in Florida, New York, Connecticut, North Carolina, West Virginia, and Maryland.