Justice, fairness, and hope: The COVID-19 pandemic, health inequities, and pediatric care

There cannot be healthcare quality without equity. There cannot be equity without acknowledging racism, segregation, and the resulting inequality of health, wealth, and opportunity. A research agenda that defines and helps explain heath disparities is a critical force for justice in healthcare. Equally important is a collaborative, dedicated community of professionals to provide that necessary, effective, and valuable care.

Ensuring a healthy present and future for our children requires an understanding that individual wellness is not the absence of disease and that quality healthcare exists only in the context of community. The distribution of health and illness in our country is more complicated than socioeconomic status. Where children and their families live, what they eat and their food security, their literacy levels, the books in their homes, the success of their daycares and schools, the work they do and the exposures these jobs entail, the quality of the air and the water they consume and their quality, their activity and access to recreational opportunities, their interconnectedness with others and the safety of these relationships – have all been related to population health.¹

“If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life.”

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Rudolf Virchow: physician, pathologist, and champion of social medicine.²

Virchow's aphorism is as true today as it was in the 1840s. Equally correct is his distinction between individual health and population health. Even more historically consequential is his awareness of the impact of the social determinants of health on both individual health and the overall wellness of the community writ large. As we now enter the third year of a deadly COVID-19 pandemic, the urgency of care obligations has, perhaps, receded enough to enable a more expansive vision of the crisis that has affected all of humanity. Unfortunately, its impact is likely to be felt most negatively by the most vulnerable of our children and youth.³

Oberg, Hodges, Gander, Nathawad, and Cutts focus on this subgroup in this timely current volume.⁴ They describe the impact of COVID-19 on children's lives in the US and its amplification of entrenched systemic institutional inequities. The immediate impact of the pandemic on all youth, while significant, is only one concern. The long-term effect on our nation's youngest is difficult to predict; however, the implications for those most vulnerable go far beyond the 13 million American children already infected. Who are the subgroups most vulnerable? They include Asian Americans and Pacific Islanders, Black and Latinx, Indigenous populations, refugee communities, those with a disability, and LGBTQIA+ youth.⁵

The authors present data that describe the maldistribution of the impact of the pandemic on those living in poverty, with food insecurity, housing instability, and disruptions of childcare, healthcare access and utilization, and education. Notably, the authors review the sequelae of the pandemic regarding child wellbeing and mental health. They also offer a series of recommendations for designing and implementing interventions that foster a more just and equitable future for our nation's children and their families.

Specific demographic and social determinants of health amplify health inequities. Health care research can now assess health outcomes by neighborhood block as efficiently as navigation by Google maps. These sophisticated research models allow unprecedented insight into the complex relationships that impact health and illness and are crucial to efforts to impact health inequalities and to promote wellness.

Oberg, Hodges, Gander, Nathawad, and Cutts clearly describe the forces that have shaped the increasing child inequities caused by the COVID-19 pandemic. These inequities result in the denial of basic needs – economic security, health care access and utilization, schooling, and mental and psychosocial wellbeing. Poverty, food insecurity, and unstable housing anchor the economic impact of the pandemic and amplify the vulnerability previously enhanced by the two previous economic downturns of this early 21st century. Health care visits, developmental assessment, dental visits, and routine and COVID-19 vaccinations have been decreased or delayed.⁶ The authors further document the loss of education and schooling opportunities, including childcare and early education, school closing, lack of access to broadband for distance learning, and the increase in social isolation. The increase in child maltreatment, suicide attempts, social isolation, psychosocial distress, eating disorder diagnoses reveals the detrimental impact of the pandemic on the mental health and wellbeing of our children.7, 8, 9, 10 The decrease in mental health service availability and increased family disruption linked to the pandemic only aggravates suffering and amplifies inequity.

Particularly troubling is the impact of mistrust of federal health messaging in many disadvantaged communities. In these communities, the most at-risk populations for severe morbidity and mortality are often the caregivers for the youngest. Sadly, in Native American communities, the disproportional loss of elders and adults strains already complex attachments for cultural and language education.¹¹ For youth with disabilities, those in foster care, and those who are homeless – a disproportional number of whom identify as LGBTQIA+, and families who are refugees and immigrants, particularly those who are undocumented and who faced enormous challenges before the pandemic, the pandemic has amplified their vulnerabilities.^{12 , 13}

The authors propose creating an equitable and just recovery for children and youth based on four categories of impacted inequities. These become four pillars to rebuild a just and fair community: 1) Family economic security, 2) health care access and utilization, 3) education and schooling, and 4) mental health and psychological wellbeing. Their suggestions are relevant for local leaders as they strive to improve equity in their communities.

“All medicine is inescapably social,”

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Leon Eisenberg MD, 1922-2009, former professor of social medicine and psychiatry, Harvard Medical School¹⁴

Quantitative data cited by the authors dramatically demonstrate the uneven impact of the COVID-19 pandemic on the most vulnerable children and youth in America. The authors do a tremendous service by their analysis. These data inform us regarding the “what” that happened to children and the “why” we should be concerned.

What does this all mean to those who provide direct health care to children and young adults? Our professional lives revolve around the “hows” of everyday life as navigated by our patients and their families – this is the social medicine that inhabits the DNA of all of us that provide child health care.

Health disparities have been studied for decades and suggested improvement projects implemented. For example, the prescient pediatrician Robert J. Haggerty in Rochester, NY, defined the concept of “new morbidities” beginning in the 1970s, contrasting the “old” scourges of infectious diseases and described for the pediatric community the psychosocial and developmental determinants of health and malnutrition.¹⁵ Doing so sets the current collaboration within interprofessional teams that effectively address healthcare inequities using evidence-based strategies. The current state of community pediatrics owes much to all caring professionals, like the current authors, who bring even more clarity to the ingrained injustices that define our nation's current state of health.

“Hope is not optimism, which expects things to turn out well, but something rooted in the conviction that there is good worth working for.”

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Seamus Heaney, Irish poet.¹⁶

Only by a focus on equity and racism can we hope to ameliorate the impact of the social determinants of health. Almost six years ago, this journal devoted a volume to child health disparities of the 21st century (Volume 46, Number 9, September 2018). In an accompanying commentary, I stated that for us as a country to ensure the wellbeing of our children, we first needed to understand the current realities of child health disparities.¹⁷ That observation remains timely today.

“Life's unfairness is not irrevocable; we can help balance the scales for others, if not always for ourselves.”

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attributed to Hubert H. Humphrey, American politician

What do we as community clinicians who care for infants, children, adolescents, and young adults do to fulfill our responsibility to provide social medicine and address illness and disease? Is there hope to improve equity? A decided yes!

Models to succeed exist for primary and specialty care. We have help. The Pediatric in Office Setting (PROS) network should soon finish the “We Care” study of implementing interventions to address social determinants of health in clinical practices. The American Academy of Pediatrics (AAP) has just published a 3-volume package on the social determinants of health for office practices to promote health equity with practical clinical intervention. As a model for specialty pediatric care, The Vermont Oxford Network (VON) of neonatal units, whose mission statement includes the concept of equity, has discarded the narrower practice of neonatal “follow -up” to embrace a more global model of “follow-through” that takes on the challenge of building an inter-professional collaborative, comprehensive approach for the wellbeing of children and their families by partnering with health professionals, families, and the wider community.

Despite constant headwinds that have always made change difficult in our healthcare system, and the additional buffeting by the current maelstrom that engulfs our nation's public health efforts by those who appear to believe fiction for truth – research such as summarized in the current publication, when combined with a community of care, will prevail. It must, our future wellbeing as a just and civil society is, in part, dependent on our success in this endeavor.