COVID-19 apocalypse for children: Predictable, preventable?

In his editorial Apocalypse Perhaps, the Editor‐in‐Chief gives us a fine and balanced analysis of the first 6 months of the COVID‐19 pandemic. I dispute nothing in that editorial. This commentary, then, is restricted to considering children and young people, and essentially argues that these age groups can reasonably be predicted to face an apocalypse from the downstream economic effects of the pandemic. I argue also that this could be preventable. I have deliberately omitted any reference to harms already apparent – they are not apocalyptic. While it is entirely unknown how the pandemic will progress, with or without an effective vaccine, I believe it is important to be ‘thinking ahead’, to make the best of the future. A hallmark of the pandemic so far has been repeated failure to take seriously what in retrospect could have been heeded and led to action.

First, although, is the joyous fact that it is very rare for children and young people to suffer severe disease and die from COVID‐19. How much worse would it be if children died more often than much older people, or if deaths were across all ages? Such a concept is controversial. It transgresses deontological ethics, in which all lives are of equal value. I believe that the inequity, injustice and loss of decades of potential life from death of a child or young person take priority in this. The virus cannot be given any moral credit for this.

No formal training in economics is required to understand why COVID‐19 is such an effective global destroyer of economies. To control it, quarantine of countries and isolation of people have suddenly decimated world trade and commerce. It affects everything where people come together: sports, hospitality, arts, tourism, air and sea travel are all severely affected. Of great importance is the fact that the ‘Health vs the Economy’ equation has been shown to be largely irrelevant – models of early response, late response and minimal response have all been accompanied by enormous economic harm. Unemployment rates are the highest in many countries since the great depression. Outlays to defray economic collapse are the highest ever. The International Monetary Fund says ‘worst since the Great Depression’, the UK Chancellor of the Exchequer ‘the worst in 300 years’. We hear independent economists admit they have ‘no idea’ of what might happen, while politicians express confidence of return to ‘normal’ or a ‘new normal’, not necessarily bad, as public confidence needs this optimism. Parallels to the Great Depression are made, following not a long time after the apocalypses of WW1 and the succeeding Spanish influenza pandemic. A global recession lasting some years now looms as a firm probability.

So children and young people, then? How much harm to them can eclipse over 360,000 deaths to date, with more to come? That number is too numbing to comprehend, but not ‘(every one) is a story, a life, a person’. We can never disregard the tragedy for so many and for their families. Yet the damage to children and young people if we have a prolonged world‐wide recession could be far greater, from the known direct consequences of severe poverty (Table 1). What numbers could be involved? One quarter of the world's 7.8 billion people are aged less than 14 years. If a conservative 5% of these children were in severe poverty it would equate to 200 million children. Yet dire consequences could be preventable, or at least reduced, via a new cooperative globalisation, re‐defining the roles of all people via economic, not altruistic strategies. New political and economic leadership and different priorities would be needed, to foreshorten the recession. Yes, this is wildly optimistic. While awaiting such miracles, what can we do, as paediatricians, individually and collectively? We can try to remain positive in the face of terrible odds, not least as the alternative is dismay and defeat. The value of excellent science over magical thinking has been demonstrated in this pandemic. Sound paediatrics has amassed a high level of knowledge of the effects of poverty in children, and defined what advances are needed. We can be advocates and activists, or support those best suited to such roles. We must see the world as it is, yet try to summon the courage to confront the greatest difficulties.

Table 1

Associations of severe childhood poverty

Childhood deprivation of	Potential permanent harms
Good nutrition	Stunting, deformity, poor brain development, intellectual disability
Protection from abuse, exploitation	Lifelong injury, disease, social disability, psychiatric illness
Education	Social, economic and intellectual disadvantage, potential for a full life
Affection, nurturing, love	Ability to love, psychiatric illness, potential for a flourishing life
Immunisation	Premature death, lifelong illnesses
Clean water, shelter	Premature death, hypothermia, heatstroke, water‐borne diseases
Access to good health care	Delayed or non‐diagnosis of serious illness or injury, permanent disability, premature death
Clean air, clean environment	Chronic lead or other toxin poisoning, chronic lung diseases