COVID-19, Violence & The Need To Act with Urgency

Amidst the fear and uncertainty of the Covid19 lockdown in China, 26 year old Lele experienced something more terrifying than the virus itself. Her husband fashioned a weapon from a kitchen stool and beat her semi-conscious as she held her 11 month old baby in her arms. There was nowhere to go, no services to support, no possibility to flee. She had to spend several more weeks with her abuser before she could reach safety.

On the other side of the world in Greenland, the capital city banned alcohol sales to prevent growing child abuse during lockdown. In India the were 92,000 calls to a child abuse helpline in the first 11 days of lockdown. France experienced a 34% increase in abuse helpline calls by children and an even bigger increase in the number of peers and school mates calling on behalf of friends. . As closed schools and stay at home orders spread, so did the risk of abuse.This pattern played out across the world, in three ways:

The first is the way that lockdown piles pressure on households . Even the calmest, securely attached and ‘child development-aware’ parents are being tested by ‘pandemic-parenting’. Often they are working in uncertain jobs while teaching ‘cabin fever kids’ while adapting to loss of space and privacy. But most will not suddenly become abusive or neglectful. In more volatile families however, this stress can spill over into violence or exacerbate existing abuse patterns. The biggest beneficiaries of #StayAtHome are the serial abusers who practice coercive control and other forms of psychological aggression. the lockdown increase the likelihood of adverse childhood experiences.

Secondly, the means of reporting severe child abuse or neglect have been dramatically reduced. According to the US Department of Health & Human Services child protection interventions are initiated by reports from teachers, social workers or nurses. Social distancing measures have reduced reporting. From the 1980s onwards increased reporting of family violence was a major mark of success and progress in protecting the rights of women and children. Momentarily, reporting is in decline.

The third issue, is complex but equally serious. In normal circumstances less than 1 or 2 % of children are subject to interventions by social workers. Yet Adverse Childhood Experience (ACE) research across populations suggests between 15 and 20% of children are affected by chronic, multiple forms of abuse, neglect or dysfunctional parenting at home. This 15 to 20% of children are now in a state of isolation. Children have a biological imperative to have protective, soothing relationships with an adult and are simply not built to be isolated. When a positive relationship at home is absent, the child interprets it at risk. It over-activates their stress response system which wreaks havoc on all aspects of healthy development. Unaddressed it can lead to catastrophic health and wellbeing outcomes throughout life. But when the stress is buffered and soothed by a healthy relationship with a teacher, grandparent or friend and the child is made to feel they matter on an individual level-then the recovery can begin. Right now around the world, hundreds of millions of children have been cut off from those relationships.

This is deeply distressing. Accounts of childhood maltreatment often recall a despairing loneliness and unbearable slowness. Loneliness when the parent who should soothe the pain, is actually the source of that pain. Slowness during long pauses of waiting for a violent outburst or scarce moments of maybe feeling loved. The isolation of the pandemic amplifies this pain exponentially. It is malleable with no end in sight. Relationships with teachers, grandparents and friends were cut off suddenly with no date for restoration.

We need to act with urgency on all three issues. Governments and communities could appoint ministers or local leaders to coordinate child wellbeing during lockdown. A priority must be engagement with parents on managing stress, home schooling and positive discipline, tailored to lockdown conditions. Online and media platforms could be adapted to facilitate a conversation with families and disseminate pandemic-specific parenting tips, similar to the global UNICEF parenting hub. Social protection and housing support must be adapted to reduce the stress on vulnerable families. Behavioural insights and technology innovations should be used to understand how we can best support parents and protect children.

Expanded helplines and channels that enable neighbours and friends to report maltreatment anonymously need to be provided . Equally we need to encourage extended family and friends to maintain regular communication with children in lockdown with abusive or neglectful parents. One of the most moving stories of the pandemic so far is the upsurge in calls by friends of victims reporting maltreatment in France.

Innovation and adaptation could help teachers and social workers restore normal levels of communication with children, despite lockdown. If they are not giving lessons, can they call each child for five minutes? These measures need to be population-wide and not just targeted to 1-2% of children who are child protection cases.

Decades ago, it became normal to ensure every child was immunised against deadly disease with a vaccine. In the future we could hope for a world were every child is buffeted from trauma by a calm and predictable adult connection. A world in which we improve prospects for parenting in every family at the earliest possible stage and maltreatment is managed and prevented as a part of routine public health . All we can do now is demand protection for Lele, her baby and millions of abused children and women locked down, unreported and isolated around the world as part of our immediate and shared struggle to defeat Covid19

A Children’s Pandemic

A month of Pandemic measures and I already wince at a handshake or touched face on Netflix. Just yesterday, New York was bustling, packed and confident. Now it is cautious, dispersed and masked. If our relationship with the world around us has been instantly transformed, what about the impact upon children in their formative years?

It may be the single blessing of this ruthless pandemic that children are least vulnerable to the virus. But sadly not the potentially deadly ricochets and aftershocks it leaves in its wake. This week the UN Secretary General reported that health and food system impacts will increase other childhood diseases and malnutrition. The number of children living in extreme poverty is projected to increase from 386 to as much as 450 million as a direct result of a new Covid19-induced economic crisis. Extreme poverty is always a killer and likely to take more children than the virus itself. Perhaps reversing 2-3 years of global progress on preventable childhood deaths.

There is barely a child on the planet whose life has not been affected by the Pandemic in some way. 1.5 billion are at home and not school. At least tens of millions of children will be born into this crisis, mostly in conditions that would have been different if it weren’t for the pandemic. Children cannot see their friends and suffer major disruptions to learning, life and play. Sports tournaments, excursions and hackathons all shelved, teenage romance on hold. A recent study suggested that prolonged quarantine in general can make a person 4 times more likely to have poor mental health. The pandemic shocks touch all children .

Fortunately many children have the shock absorbers of a safe home, loving family and freedom from poverty, social exclusion or war. If just one from the set is missing, the impact of the pandemic is likely to be deeper and life-changing. There is now a new single thread of additional vulnerability tying together children in tightly packed slums in African cities with those in camps in Syria and Yemen. It extends to the low income children in rich countries like the UK and US and those at risk of severe acute malnutrition in the poorest countries. It also hits the approximately 5% of the world’s children with disability and the 15-20% in seriously dysfunctional, neglectful and violent homes. This pandemic has been merciless in piling more pressure on to those least able to absorb it.

The bottom billion have no means for social distancing or hand washing. Their health systems often have just a few ventilators and Intensive care beds. They are not thinking of flattening the curve, but rather a couple of dozen cases flattening their entire health system. Prevention of other childhood diseases is already disrupted, including vaccination programmes on hold in 23 countries. 30 million conflict affected children are dependent on humanitarian assistance which is likely to be battered as supply chains buckle and aid financing and fiscal space contract. 40% of the world’s children don’t even have hand washing facilities.

Remote learning is a great solution for most children, but even here in New York city it is estimated that 300,000 low income children don’t have the digital means to participate. School closures will widen the two main learning gaps. The first between countries with high performing education systems who have the agility and means to switch and those countries which cannot run their education system effectively at the best of times. The second gap is between the learning outcomes of wealthy and poor children within countries. 368.5 million of those poor children have also been cut off from essential school feeding programmes which are often the only source of nutrition. Children in need of special learning support at school or dependent on relationships with teachers and friends to mitigate the pain of violent and neglectful homes are suddenly adrift. All against a rising backdrop of increased reporting of intimate partner violence and child abuse from India to Greenland to Australia and all points in between.

If the Coronavirus was a pantomime villain waiting behind a curtain for an opportune moment to pounce, it did so with precision. Thus far, dwindling internationalism has made us too weak to address the Pandemic in the whole. But you cannot partially address a pandemic. Even during the Cold War, the USSR and the West realized this and joined forces to end smallpox. And thats what our polarised world needs to do now. If everyone is not safe, no-one is safe. The virus shows our interdependence and in the end, maybe thats its virtue.

This is not insurmountable. WHO, UNICEF, the Red Cross, scientists and artists have joined forces in the Solidarity Fund to mobilise resources for a vaccine and for prevention and response work in low and middle income countries. Scientists shared the genetic sequencing on the virus very early on and are collaborating across borders despite nationally-minded governments. There is also a global initiative to galvanise leaders into more collaborative and internationally-minded policy-making in response to the pandemic.

We have also seen national governments and societies prioritise children. 83 countries have adapted their social protection systems to help shield poor families and children from the crisis. Health, education and social work systems have often adapted to maintain basic services. Armies of school and health volunteers are helping minimise the impact of the pandemic upon children.

We should now see maintaining supply chains, aid flows and health systems in poor and humanitarian contexts as a first line response for us all, even though it seems far away. Look how far the virus has already travelled. We may also need to invest in social protection to help the bottom billion socially distance, particularly those in densely packed and poorly resourced urban slum and refugee/migrant camps.

In wealthy and poorer countries alike we should support adaptions for teachers and social workers to have exactly the same amount of contact with children as they had before the crisis and for school feeding programmes to be delivered to homes. When adapting education we need to prevent remote learning widening the gap between wealthy and poor.

Albert Camus may have appreciated the importance of teacher contact and continued learning. In 1957 he dedicated his Nobel Prize for literature to the teacher who was there for him in the midst of poverty and adversity. His masterpiece The Plague is once again a bestseller and remains a testimony to our interdependence and collective strength in the face of this crisis. In it, he wrote: “No longer were there individual destinies, only a collective destiny, made of the disease and emotions shared by all.” .

Reasons to be Humble

It is humbling to work on global health and humanitarian communications in this moment. The vastness and vulnerability of the human race are breathtaking in equal measure. Talking with people in Nairobi, Geneva or Bangkok on how Covid19 could quickly collapse a fragile health system in a conflict zone or disrupt a medical supply chain on one continent causing a deadly drug shortage on another. Consulting on strategies for incentivising rebellious European teens to stay at home or to help impoverished children in low income countries stay safe without soap and water. Even the uncertainty of where we are heading. We are all vulnerable, in different, but equal ways. There is no ‘us and them’ this time.

People in Liverpool, Lagos and Laos are all social distancing and uber- handwashing as the virus wafts right across isolationist and nativist barriers. The nationalist orientations of just yesterday seem small and redundant today. We are on a war footing with a deadly enemy, but Covid19 is not an ethnic or ideological foe. Like all living things it simply wants to reproduce. We cannot counter it with an alternative ideology. We need the two things that populism seeks to diminish: science and international collaboration. A solution found in one country or more, will become a solution for all countries everywhere.

I have been lucky to work alongside epidemiologists in large scale humanitarian responses, but never on this scale. Public health, along with universal education and social protection, are amongst the UN’s basic international human rights tenets. In disaster and war, maintaining public health is a recognised humanitarian principle. Good public health is when societies improve health outcomes for all: reduced child mortality, non-communicable disease and longer life expectancy. It is also our first line of defence against a deadly enemy like Covid19.

The global child survival revolution of previous WHO/UNICEF and public health generations dramatically reduced child mortality by attacking disease transmission. For the first time in history, major childhood diseases were stopped in their tracks. This occurred through herd immunity via mass immunisation and access to clean water and sanitation. Vaccines, clean water and Sanitation transformed our world beyond recognition and still stop more deaths than any invention since. This is the reality that many of our societies have come to take for granted for the past few decades. Until now.

Pandemics recede when the basic reproduction rate drops way below one. This is the average number of people someone with the disease will infect. The current basic reproduction rate for Covid19 is estimated at between 2 and 2.5. It is much more infectious than regular flu which has a reproduction rate of 1.3, but much less infectious than measles with a rate of up to 18.

Without vaccines or herd immunity for Covid 19, we need other means of reducing transmission. Mass testing and then isolating and caring for cases is our primary form of attack. Social distancing and rigorous hand washing are the best defensive assets we have. Often these public measures are challenging as recent politics has shrunk space and trust for public intervention. We need to rebuild it to defeat Covid19. In doing so we can build a more cohesive society, as many places did after the second world war. This is up to us.

I have seen children die in countries where herd immunity and vaccine confidence has dipped following a concerted anti-vaccination campaign . The Covid19 crisis is only a very moderate version of where they would take us. The anti-vaxxers and their friends would unravel decades of progress on the major childhood diseases and leave our children exposed to something much worse than Covid19. Deadly diseases, including measles, with a basic reproduction rate of between 5 and 18.

One example is Polio. Only two generations ago Polio was every parents worst fear. The paralysing, life changing and often deadly disease has a reproduction rate of between 5 and 7. In 1955 Jonas Salk, a virologist from a working class, Jewish migrant family in the Bronx became a global hero when he found a Polio vaccine.

Just 60 days into Covid19, we already have a vaccine being trialled. This is unprecedented and would never have happened if countries had not put the genetic sequences out in public. It will probably be a multi-national team of Jonas Salks who will deliver the final vaccine to defeat Covid19.

Mostly now we are seeing the best of ourselves. We can see that the values that have recently stripped employment rights, public services, science and international collaboration to the bare bones are flimsy and reckless. We can see that wealth makes you no less dependent on the at-risk front-line health worker or low-paid food delivery person. It is a humbling time indeed. Maybe that humility will help us regroup, rethink and defeat Covid 19. And then build a better tomorrow.

A Tale Of Two Pandemics

Will Covid19 Widen Inequality?

With Rugby & Football postponed and social gatherings replaced by social distancing-the only hope for an exhilarating weekend was a long bicycle ride. As Hudson suburbs gave way to inner city Bronx & Harlem before the more prosperous heartland of Manhattan- a simple bike ride shows how different income groups cope with Corona Virus. In prosperous neighbourhoods, cafe bars and barbers shop were half or three quarters empty. There was not a hipster to be seen. By contrast, poor migrant areas were bustling. It’s a bike ride-not a piece of scientific research. But do high rents, poor pay, insecure employment, no sick leave & “for profit” health systems prevent the poor from social distancing? Do they need to carry on as normal? Even when they are frightened of the virus?

We may all be frightened of getting sick. But the poor often fear the sickness itself less than the life consequences. One pay check away from homelessness, the potentially ruinous out of pocket hospitalisation costs or the direct relationship between todays work-shift & tonight’s family meal. Over time the secondary costs will hit the poor the most. If children are out of school, who will look after them? Online learning is a brilliant solution for social distancing, but those who already have the worse learning outcomes also have the worse connectivity: the poor. In the end, there will be job layoffs. Corona virus will break some businesses and the working poor will be the first to go.

27 million Americans don’t have health insurance. The world’s wealthiest country equals many middle and low income countries in having dramatically worse health outcomes for it’s poor. Brits shouldn’t be smug. Low income males in the UK die almost ten years earlier than the wealthy. Many of the non-communicable diseases and conditions that render Covid 19 lethal are much more prevalent for those in poverty. In the poorest countries on the planet, weak health systems may be overwhelmed by Corona Virus. This will divert resources from other child killers such as ebola, measles, cholera and pneumonia.

Child poverty is not the only driver of lifelong inequality. Adverse childhood experiences such as family violence and neglect also lead to serious inequality throughout adulthood . How do you think #StayAtHome sounds to a child who only feels safe when they are not at home? Whose only soothing & supportive relationship is with a teacher or a school deskmate. The pandemic will turn their already fragile world upside down and minimise their chances for recovery. When schools were closed during the Ebola crisis in West Africa increased rates of sexual abuse and exploitation of children were recorded.

Privileged cultures, wealth and education rightly equip children with skillsets to better navigate complex challenges in a way that often eludes the less well off. This is highly relevant in a pandemic. The ability to distill a stream of useful facts about the virus amidst an explosion of noisy fake news. The agility to regularly absorb and update ones knowledge and act up upon it. Adaptation to change and uncertainty and knowing where to seek help. When something goes wrong for a poor or high-adversity kid and they are knocked off course, it takes them much longer to get back on their feet.

In many countries including the US and UK, inequality seems to be expanding and social mobility declining. If you grow up without university educated parents, your future prospects seem to be in decline. It is rarely articulated, but deep in the sub-conscious of working class and poor people this trend has transformed voting trends. Growing inequality has created space for populist braggarts who shun science and international cooperation. The very people who now appear shrivelled and sheepish next to scientists with international networks of practice.

Covid 19 is not just a public health crisis. It will be an economic and social crisis, a jobs crisis, a housing crisis and it will certainly be a child crisis. It needs a social strategy as well as a public health strategy. Are we the Italian balcony Sopranos who celebrate our shared humanity by singing our hearts out together? Or the hysterical supermarket goers who elbow each other out the way to buy endless supplies of loo roll? I think time will show us to be more like the sopranos, but that social strategy needs to bring us together rather than build wedges to drive us even further apart.