Preventing Covid-19 health inequities: An urgent duty of care to children in poverty

By Prof Innes Asher, Dr Jin Russell, Prof Nikki Turner, Janet McAllister

“We owe a duty of care to those vulnerable New Zealanders” – Prime Minister Jacinda Ardern, referring to children and people with health conditions, announcing the vaccination mandate for education and health workers, 11 Oct 2021.

Figure 1: The interaction between Covid-19 socioeconomic impacts and their inequities (WHO, 2020, p8)

Covid-19 inequities are set to increase in new ways

Up until now, the effects of Covid-19 on Aotearoa New Zealand have been primarily social and economic, and related to Covid-19 containment measures. Now, however with the arrival of Covid-19 delta into the community – in part due to already existing ethnic and socio-economic inequities –health inequities may increase dramatically with huge potential to be disastrous for Māori and Pacific communities (as modelling indicates), low-income communities, people with disabilities, other vulnerable populations and the country as a whole.

Expected health inequities for low-income communities are due to factors such as: high levels of crowded housing and insecure housing, and lower vaccination uptake increasing Covid-19 spread; and high levels of underlying disability, health conditions, poor nutrition and lower access to healthcare exacerbating its consequences. In the UK in 2020, researchers found deprivation and Covid-19 deaths to be strongly linked – people in the most deprived areas had a greater chance of dying from Covid than people in the least deprived areas, and very little of this increased risk was explained by pre-existing disease or clinical factors, suggesting that other social factors have an important role. (It is unclear what these social factors are, and how much they pertain to the context in Aotearoa NZ. For example, the World Health Organisation suggests that early testing increases the chance of timely medical intervention – and people who cannot afford the financial implications of a positive Covid test are less likely to get tested early.)

Health inequities lead to further socio-economic inequities, as illness often means loss of earnings, unless policy (regarding sick leave, for example) is further changed.

Government has a duty of care to mitigate these inequities, which requires policy shifts

The Government can mitigate such iniquitous outcomes and help lower the disease’s social and economic burden for the country as a whole, by managing public health with the best interests of vulnerable populations at the centre. This requires further placing of trust and resources in Māori and Pacific expertise, and community organisations in health and other sectors who have the knowledge, community’s trust and relationships required to make a difference. Schools need to be provided with gold-standard public health plans. At the same time transformative policies are needed to address all factors contributing to high risk of preventable disease including ensuring all families have adequate incomes, stable healthy uncrowded housing, effective social network support, access to affordable primary health care and mental health services, and health services that are responsive to local community needs

Inequities for low-income children may include Covid-related caregiver illness, incapacity and death

One of the reasons why Government needs to urgently increase resources for health care and financial support for low-income communities is to reduce the impact on children who have caregivers and loved ones who will experience serious effects of Covid-19, requiring primary health care in the home, hospitalisation, or potentially death. Low-income children are more likely to face these devastating consequences. For example, children in low-income communities are more likely to have family members with disabilities or to have disabilities themselves – which suggests they are potentially more likely to experience severe Covid-19 symptoms than others.

For children who live with one sole caregiver – children in low-income communities are more likely than others to do so – there may be little or no ‘back-up’ if that caregiver gets sick or is incapacitated for any reason. Or if there is back-up, their care arrangements and primary caregiver may have to change, adding to what will already be an anxious time.

Overseas, sometimes multiple adults in a family have become ill at the same time, and so children have no close family to care for them. In Australia on social media, hospital workers shared stories of children isolated in hospital because their parents are ill:

A heartbreaking eye-opener was stories of children being separated from their parents, and cared for by strangers in hospital because they are considered ‘infectious’.

“Parents in ICU or almost at ICU level often have no one to care for their children because the virus has spread to multiple adult family members often multiple people hospitalised," one wrote.

"Children are classed as infectious, sent to another hospital ward to wait to see if their parents survive. iPads are set up in cots so babies can see or hear parents.”

While another commented, “Teens/Kids left to look after siblings with mum/dad in hospital.”

Overseas, between 1 March 2020 and 30 April 2021, approximately 1.1 million children lost their primary caregiver due to Covid-19; a US study found children left bereaved were disproportionately within ethnic minority communities. While overseas responses may not always be appropriate in the Aotearoa context, they can prompt useful questions, and can sometimes dovetail with local expertise. For example, researchers in the US recommended “strengthening family-based care” and avoiding institutionalisation, while others warn that supporting “programs that target one type of vulnerable child (e.g., an ‘AIDS orphan’ or ‘COVID orphan’) can be highly stigmatizing and inefficient”; instead, what they recommend as useful is anti-poverty initiatives and additional resources for counselling in schools—“programming that is more universal, but still sensitive to the needs of these children”.

We urge the Government to consult urgently with community and consider how best to protect and support children whose caregiver/s are incapacitated by Covid-19.

CPAG recommendations to Government to reduce the inequities of the Covid-19 disease burden on low-income children

Uphold Te Tiriti o Waitangi

1. To uphold te Tiriti o Waitangi, and slow the spread and reduce the consequences of Covid-19, take all necessary measures (as indicated by Māori communities) to ensure whānau Māori are not further inequitably burdened with Covid.

"We felt incredibly vulnerable and were reflecting on how many of our people died during the 1918 flu epidemic. You don't have to go far around here to see urupā full of our people from that time. …We were pretty highly motivated to protect our people. Here we know our people, so we want to protect them as much as we possibly can.” Te Kaha Medical Centre GP Rachel Thomson, successful in ensuring high early vaccination up-take within the iwi rohe of Te Whānau ā Apanui.

Slow the Spread to Disadvantaged Children & Their Families

“We do not care what the current strategy is called as long as we persist with border protection and public health measures until we achieve close to universal vaccination. Otherwise, many thousands of New Zealanders will be hospitalised, die or experience long Covid.” Prof John Donne Potter, Graham Le Gros & Prof Rod Jackson, 11 Oct.

1. To reduce the inequitable disease burden on low-income Pacific and other vulnerable families (such as people with disability, refugee and migrant families), support further increase in empowerment and resourcing of Pacific and other local community -led public health responses such as vaccine rollout.

2. To reduce inequitable disease burdens in vulnerable communities, we strongly support the efforts towards equitable vaccination delivery approaches before public health protections are eased. These need to reach everyone in: low-income communities; Māori, Pacific, and refugee populations; transitional housing; emergency housing; households with disabilities; multi-generational households; and prison populations.

3. As a matter of urgency, identify and implement responses to minimise the risk of infection in emergency and transitional housing. This is likely to require increased accommodation capacity and increase wraparound support – these should both be sought and resourced as an immediate priority.

4. To protect children in education and health services: Ensure all schools and health services (PHOs, dental clinics etc) have evidenced-based plans re ventilation, filtration and mask use, and resource and equip them to implement them in a timely fashion. Ensure these are finalised and in train before schools reopen further.

Ventilation is a valuable protection that works well in combination with other pandemic control measures such as vaccination and mask use, with additional benefits for improving children’s learning and concentration… Dr Amanda Kvalsvig et al, Sept 2021

Not only does better ventilation and cleaner air protect children from Covid-19, air purifiers are also able to clean out Staphylococcus, Streptococcus, and other viruses from the air. – Dr Jin Russell, Oct 2021

1. To protect disadvantaged children: Ensure everybody is able to self-isolate while waiting for test results (up to 4 days) without needing to seek additional income assistance, by pre-emptively ensuring income adequacy for all. It is vital that total tax credit assistance for families (Working For Families) is not reduced as is currently the situation when families require a benefit. An increase in income support for all low-income families (both in paid work and those without) would also encourage people to come forward with symptoms with more reassurance that they will be assisted and supported when they do so.

"Our Pacific Provider and Community Vaccine response is about no barriers, walk-in/drive-in, using established networks for communication, using community venues, offering food parcels. But the poverty and need in our community is marked and getting worse" – Dr Teuila Percival

There has also been a hesitancy among some Pacific people to get tested for Covid-19. This is in part due to fear of having the virus, but also a fear of needing to take time off work, and of placing a financial strain on family as a result. - Dr Maryann Heather

Poor nutrition... is the pre-existing condition that makes some more susceptible to Covid-19 - Professor Elaine Rush

1. To protect disadvantaged children: Follow community public health advice as to what housing circumstances are required in order for people with Covid-19 to self-isolate safely. Ensure those whose housing situations do not allow safe self-isolation have the option to move to an MIQ facility.

"You've got to be quite clear about the criteria [for self-isolation]… It can't be a small state house with three bedrooms and 12 people." Dr Collin Tukuitonga.

1. To protect disadvantaged children: Ensure people with Covid are given appropriate, well-resourced community support when isolating.

“When people do get sick from COVID is there community/social support for them? Overall - stressed households with low income, poor nutrition, poor housing and increased rates of disability will have a greater burden of disease - social support for these households is inadequate.” – Health leader

Reduce the Consequences of Covid for Disadvantaged Children & Their Families

      9. To better support disadvantaged children with timely and effective access to health care (for Covid & other reasons) and to protect them from the suffering and debilitation of loved ones and caregivers: Urgently increase support and resourcing for primary health care in low-income communities.

     10. To protect disadvantaged children when they and their families experience Covid: Consider with urgency and genuine community consultation how best to protect and support children:

       i. in houses where it is not possible to self-isolate.

       ii. whose caregiver/s are incapacitated by Covid-19, and/or have to go to hospital.

By following these recommendations which are made with the best interests of vulnerable children in mind, the Government can help lower the disease’s social and economic burden for children in poverty and for the country as a whole.