In our rush to ‘live with Covid’ are we jeopardising children’s futures?
Science and Ethics suggest we need a rethink
Imagine a world where half of all children perished before adulthood, and the despair and suffering this would cause. Until relatively recently this was our world. Irrespective of location, culture or historical era, every second child died. Even as recently as 1950, globally one in four children still died. The chances of reaching adulthood dramatically increased only as a result of public health progress over the last 100 years or so, and controlling infectious disease was the main driver for this progress.
In the UK, the first momentous step taken to reduce child mortality arrived with the Public Health Act of 1848. This reforming Act was a result of a ground breaking report produced by the health reformer Edwin Chadwick. His genius was to combine statistics with the prevailing descriptive narrative of the appalling social conditions that led to frequent outbreaks of disease. The 1848 Act provided for clean water, proper sewers, and weekly refuse collections, but most importantly, it set the precedent that the state was responsible for the management of public health. Chadwick, while a Utilitarian, was motivated by both ethical and economic considerations. Disease created huge costs in poor relief – welfare benefits in modern parlance - and an unhealthy populace was not economically productive.
Ever since Chadwick’s time, the synchrony of moral philosophy and scientific data has been instrumental in guiding public health policy, with the primary focus placed on re-engineering and controlling the environment for the benefit of all. Bolstered by the development of vaccines and other pharmaceutical tools, public health has not only dramatically reduced child mortality but also gave children a greater opportunity for longer and healthier lives. Today the chance of a child surviving and reaching adulthood is 96% globally. Paradoxically, this has now led to a widespread assumption that children are ‘robust’. Looking back, the stark historical record on child mortality suggests otherwise. If we expose unprotected children to disease, a longer, healthy life, filled with opportunities, is not guaranteed.
In 2020, Covid, a complex multi-system disease , which can damage a wide range of organs, invaded their world, challenging their health and disrupting their education. In our attempt to ‘live with Covid’, most adults have the autonomy to make choices. We can ignore, engage with, or reject the available scientific data. We can take precautions or choose to gamble with the repercussions of being infected. Children have no such agency, and therefore have no choice. Without a systematic, critical evaluation of our assumptions, can we be certain we aren’t jeopardising their futures?
Societies through the ages have often followed paths that they believed were justifiable at the time, only to find later, with reflective reasoning, such beliefs were unacceptable. Dangerous futures can also arise when societies choose to reject or ignore knowledge – the “Galileo Effect” inspired by the cardinal in Brecht’s play Galileo Galileo who refused to look through a telescope to avoid the evidence that the planets revolved around the sun. We should not assume we are today immune to the Galileo Effect – think global heating and what climate science was telling us in the 1980s.
From the start of the pandemic many assumptions about Covid and children became entrenched within society. It was claimed that “Children were more likely to be hit by a bus than catch Covid”. Some in the medical and science establishments were too hasty in declaring that children were less susceptible to Covid and subsequent post-Covid health impacts - ‘Long Covid’. Unexpected surges in other illnesses have been blamed on long-past lockdowns – so called “immunity debt”.
We now know that children are both victims and vectors, and that children play a substantial role in disease transmission. Most studies of Long Covid have focused on adults, resulting in an underestimation of the prevalence of pediatric Long Covid syndrome. Current estimates indicate at least 16% of children suffer from Long Covid with each infection, and an analysis of 40 million healthcare records in Germany showed that children are just as susceptible to this condition as adults. The evidence for biological mechanisms leading to Long Covid is now overwhelming, and it is accepted that SARS-CoV-2 can spread to multiple organs and persist for months in children regardless of the severity of the initial infection.
Chronic, persistent symptoms lasting for months, years or even decades following infections are not unique to Covid and have been documented for many other diseases, including Lyme, Dengue, Ebola, Polio and SARS-1. The fact that Covid shares this intrinsic characteristic is highly concerning, as with each sweep of the virus more children will potentially be left with long-term disabilities.
Counter to the initial assumptions, children can also suffer lasting neurological symptoms with the most common being memory and concentration deficits, sleep disturbances, anxiety and depression. Perhaps even more insidious are the biomarkers for persistent lung and heart damage post Covid. One study found that an average six out of ten previously healthy children displayed heart impairment after an asymptomatic or mild Covid infection. When a Senior Consultant Cardiologist at Newcastle’s Freeman Hospital such as Dr Rae Duncan, asks the question “what is Covid doing to our children?” we should sit up and pay attention. Whether or not these abnormalities resolve with time she says is not known, but with the prospect of children being repeatedly infected, she strongly advocates for a very cautious approach to Covid.
So called “immunity debt” is also becoming increasingly difficult to justify as more time elapses since the removal of all protections. Babies born well after the last Covid measures ended are suffering elevated rates of invasive Group A Strep (iGAS), and a strong body of evidence now implicates the role of a prior Covid infection in the recent surge in severe RSV cases in young children.
The belief that ‘immunity debt’ is behind these worrying health impacts is just that – a belief. There is no scientific evidence for the concept. If close social contact and exposure to abundant pathogens strengthened immunity, the children of 1848 would have been very healthy indeed, and there would be no place in history for Chadwick. Assuming that children are largely unscathed by the SARS-CoV-2 virus has not only slowed the pace at which scientific data has been gathered, but is arguably irresponsible and dangerous. The science is now ringing loud alarm bells. In the words of Dr Dick Zoutman, Professor of Infectious Disease at the University of Toronto “The fact that SARS-CoV-2 persists in our children should send shock waves through our society and compel us to do more to protect our children from Covid.”
Sir Edwin Chadwick (Licensed under CC BY 4.0.)
Deterioration in children’s health is having a major impact on their education. It is well established that health and education are inextricably linked. Poor health leads to increased absenteeism, high drop-out rates and squandered futures. In the words of Professor of Health Education, Cynthia Woford Symons, “No curriculum can compensate for deficiencies in student health status.”
The school absenteeism figures are shocking. Government figures show that the biggest single factor is sickness. Over half of persistent absence is also due to illness. Children are becoming sicker. This shocking situation is also reflected among teachers, with record levels of absenteeism due to illness. Along with healthcare, the educational sector now has the highest levels of occupational Long Covid. Teachers are also becoming sicker. Assumptions such as “behavioural changes”, “culture shifts” and “lack of social contact” due to long-past lockdowns are often flaunted as explanations for children’s lost days from school. But these explanations cannot be relevant for teachers. The common denominator that links this dramatic rise in absenteeism in both children and staff is the presence of a novel, highly transmissible pathogen.
Meanwhile, The Department of Education, OFSTED, the Children’s Commissioner, and most headteachers and school governors, remain near silent on the issue of protecting children from this disease. Perhaps for some this is due to a reluctance to engage with the scientific data- the Galileo Effect. For others, it may be a genuine belief in misguided assumptions. Others may simply believe it is too costly to invest in the infrastructure necessary to protect children, and that catching Covid is inevitable. For whatever reason, ignoring such risks to children is unacceptable. To paraphrase Dr James Wilson, Professor of Philosophy at UCL, a neglectful state is a far more worrying prospect than an interventionist government. This is no less true when it comes to children’s futures.
Poor air quality is known to cause reduced academic achievement. Studies are now showing that ventilation and filtration systems in schools can reduce the transmission of Covid by more than 80%. Installing air filters in all English schools would cost less than half the cost of the proposed Royal Yacht. The ‘do nothing’ option is far more expensive, with additional costs for children’s healthcare, academic support for those falling behind, and strained school budgets to cover staff absences. The US Federal government has allocated $123bn for clean air in schools because they see this as a cost saving measure. Without protective measures, it is not hard to imagine many of today’s children growing up facing shattered dreams, opportunities lost and work place discrimination.
Many of our assumptions and beliefs regarding Covid and children are incompatible with the current scientific data, and clinging onto these risks society following paths that place children’s futures in jeopardy. Uncertainties remain regarding the full extent of the long term damage from this virus, but ethics should propel us to act out of sympathy towards children and do our utmost to protect them from further suffering. Under these circumstances the precautionary principle – part of the ethical umbrella we use to protect citizens from future dangers – becomes essential.
Ever since those first momentous strides in public health, ‘living with pathogens’ has always meant suppressing and driving them towards elimination – in other words we ‘throw the kitchen sink’ at them. Never has it meant ignoring or even encouraging infection, as we are doing today with Covid. Looking back, Chadwick’s radical public health proposals met with fierce resistance, but were he alive today, he would be pressing hard for new public health measures – the Control of Airborne Pathogens Act, 2023, perhaps? And if he were successful, we would still be talking about this revolution in another 170 years.