Integrative approaches required to support children affected by COVID-19.

Combining fertility and excess mortality rates, Juliette Unwin and colleagues estimate 5·2 million (95% credible interval 3·6–5·7) children lost a caregiver to COVID-19 between March 1, 2020, and Oct 31, 2021. Their modelling represents an ongoing attempt to hit a moving target—heart-wrenching and unavoidably incomplete. Beyond updating earlier estimates, the authors add value through describing orphanhood “by time, person, and place”. In doing so, they draw attention to the importance of dynamic, multilevel systems in shaping the crisis. Orphanhood increases a range of economic, social, educational, and health risks. To best protect children, we must consider the individual, family, community, national, and global factors that affect their wellbeing, and how these can be integrated in an adaptive response.

Unwin and colleagues thoughtfully stratify orphan estimates across many key factors, including the child's life stage, gender, parent's gender, geographical region, and time. By providing estimates disaggregated by age, we are reminded that orphaned adolescents require support for personal autonomy and transitioning to adulthood, whereas younger children require more immediate, full-time nurturing. Similarly, the breakdown by gender highlights distinct vulnerabilities. Girls might be more likely to be expected to take up household responsibilities, and subsequently underperform academically; they are more likely to suffer sexual violence and exploitation.

All orphaned children will miss the interpersonal investments of knowledge, guidance, practical, and emotional support from deceased parents. The gender of the deceased parent will affect specific familial contributions often prescribed by cultural norms. In many cultures, paternal orphans will suffer more financially, potentially contributing to food and shelter insecurity. In many cultures, maternal orphaned households will suffer more from losing social and emotional stability, potentially increasing the risk of child neglect and abuse.

As Unwin and colleagues note, young people require support to cope with the many risks that orphanhood imposes. Too often, interventions are narrowly focused on building only individual, psychological ruggedness rather than also building household-level and higher-level resilience. A thoughtful approach will recognise that there are important differences in what families need related to how deceased parents uniquely contributed. Cash transfers, investments in the mental, social, and parenting skills of guardians, and nurturing social networks can be effective at building caregiver and household resilience.5, 6 Interventions should be tailored to offset specific challenges within each orphaned child's and household's unique circumstance.

Community and cultural factors also influence the degree to which, and resources by which, orphaned households receive support. Schools can be more responsive to the range of adversities faced by COVID-19 orphaned families, and can invest in the nurturing capacities of teachers and administrators. Faith organisations, civil society organisations, and other hubs of community life could implement programmes to support the economic, social, educational, and health challenges of orphaned children based on household and individual needs. Community groups, schools, and clinics could strengthen bereavement support and sensitise providers to resilience-enabling mechanisms for children.6, 7

Unwin and colleagues explore relationships between orphanhood and context. Orphanhood rates, and related adaptive capacities across the levels of individual, household, community, and society, vary substantially by country and region. In high-income countries, vaccine hesitancy contributed to orphanhood; in lower-income countries, scarcity of available vaccines contributed to orphanhood. In higher-income countries with more individualistic cultures, a lower sense of shared responsibility for all children might limit the response to supporting COVID-19 orphans. In low-income countries with more collectivistic cultures, financial strain might limit practical responses to supporting COVID-19 orphans. Each global region, country, and community will have to investigate available assets and challenges to supporting an adaptive, synergistic, and responsive approach that is informed by the needs of orphaned children and their most immediate caregivers.

Finally, the authors draw attention to the dimension of time. The pace of COVID-19 orphanhood has risen drastically. Between the first 14 months and next 6 months of the pandemic, the global incidence of orphanhood more than doubled from about 127 000 per month to just over 250 000 per month. This increase occurred when vaccines were widely available in many countries. Since then, a new variant (omicron) has increased mortality again, and future variants might again change the geographical pattern of orphaning. Optimal interventions will continue adapting to young people's changing developmental stage, specific situation, and cultural context.

Unwin and colleagues focus our attention on children and adolescents who are affected by parental deaths; it is worth remembering post-acute COVID-19 syndrome (ie, long COVID-19) has not been well defined yet. We do not know population prevalence or case trajectories for long COVID-19, or how long COVID-19 presents challenges to affected parents and their children. Children of parents with other chronic health challenges face various social, physical, educational, and economic adversities. These potential adversities will need to be explored among parents with long COVID-19 to inform multilevel, multisystemic responses to support child resilience.

COVID-19 orphanhood confronts us at a time nearing resource exhaustion across multiple systems. The consequences of orphanhood linger throughout the course of a lifetime, affecting futures of families, communities, and societies. We determine how long our communities will suffer the effects of COVID-19 by urgently determining the quality and force of our concern for orphaned young people.

We declare no competing interests.