The spread of the new coronavirus has forced all nations to reckon with the health of their own healthcare systems. The virus has extracted the greatest toll of our elderly – not only because they have weaker immune systems but also because many of them haven’t been able to access good-quality healthcare soon enough. The rest of the population plays the important part of transmitting the virus.
However, conversations about the virus’s spread have focused predominantly on these two demographic groups at the expense of a third: the children.
In a study published in the journal Nature Medicine on March 13, Chinese researchers observed that severe symptoms of COVID-19 were less common among children than in adults. Children who had been infected in China mostly either displayed mild symptoms or no symptoms at all, and only one of them died.
The US Centers for Disease Control and Prevention (CDC) has also said that even though all children won’t develop severe symptoms as adults, they will be affected by the virus and potentially spread it to others. The agency also admitted that at present, it knows very little about the full extent to which COVID-19 affects children in general.
In another preprint research article publicised by the official journal of the American Academy of Paediatrics, researchers reported that around 90% of child-patients in China were asymptomatic or had mild to moderate symptoms.
One reason for such moderate impact could be that the new coronavirus can invade any cell in the human body that manufactures the ACE2 protein, and these proteins aren’t fully matured, functional and/or sensitive in children as they are in adults. Studies have also shown that since children often experience respiratory infections, their bodies may be able to produce more antibodies to fend off the virus.
Researchers had observed similar differences between adults and children during the severe acute respiratory syndrome (SARS) pandemic in 2002-2003, and concluded that children and adolescents were only moderately affected then as well.
However, none of the studies have completely ruled out the possibility of severe infections among children, especially among those younger than 5 years. So India’s hospitals should be prepared to face any unprecedented situation related to paediatric patients.
As with people of other ages, the impact of the new coronavirus on children also depends on the children’s health as well, and those children with poorer immunity due to deficiencies might be more at risk of developing a more severe infection should they get the virus. The data on this front in India isn’t very encouraging.
A government report entitled ‘Children in India 2018 – A Statistical Appraisal‘ paints a grim picture of child health in the country. According to the fourth National Family Health Survey (NFHS-4), 2015-16, 38% of children under five are stunted (short height for age), 28% are wasted (thin for their height) and around 36% under five are underweight. Around 59% of children are also anaemic.
Various studies have shown that iron deficiency, leading to anaemia, can weaken the immune system and increase morbidity due to infectious diseases. Only 62% of children aged 12 to 23 months receive all basic vaccinations, according to NFHS-4. And only 10% of children aged 6-23 months receive a minimum acceptable diet in India, rendering them more vulnerable. The vulnerable status of children in India reflects the overall condition of the nation.
According to the Global Multidimensional Poverty Index 2018, published by the University of Oxford and the UN Development Programme, in spite of reducing poverty from 55% to 28% between 2006 and 2016, India still has around 364 million people – the most in the world – in multidimensional poverty. (This number is higher than the combined populations of Germany, France, UK, Spain, Portugal, Italy, the Netherlands and Belgium.) Of them, around 156 million are children and 27.1% – around one in four – are younger than 10 years.
In the Global Hunger Index, India was at the 102nd position out of 117 countries in 2019. The index accounts for undernourishment, child wasting, child stunting and child mortality. The report accompanying the index observed that child wasting and stunting rates in India are very high in terms of public health significance, and highest among all countries in the report.
These metrics together render the Chinese studies discussed earlier less relevant in the Indian context because China’s health indicators are much better. The 2018 statistical monitoring report on the implementation of China National Program for Child Development (2011-2020) states that only 3.13% of children in China are underweight. Further, only 5.44%, 1.11% and 1.43% of children under five are anaemic, stunted and underweight, respectively. Additionally, more than 95% of them are covered under the National Immunisation Programme.
Anyway, poor health infrastructure has only abetted the pitiable condition of many of India’s children. The government’s allocation for healthcare is among the lowest in the world, and even before the pandemic touched India, the country had a shortage of 600,000 doctors – including 230,000 paediatricians – and 2 million nurses. Almost 65% of the health expenditure is out-of-pocket, and doing so pushes 57 million people deeper into poverty every year.
Paediatric ICUs are also in short supply. The National Health Mission insists on the presence of a paediatrician at every community health centre, but as of March 2018, there was an 83% shortfall of paediatricians in India. Further, a 2016 WHO report on the health workforce in India also highlighted widespread under-qualification: around 57.3% of allopathic doctors in India didn’t have the requisite academic credentials to be a medical doctor.
In such a scenario, children belonging to vulnerable social groups like those of scheduled castes, scheduled tribes and other backward classes face challenging times in the next few weeks if the community spread of COVID-19 comes to be. The large disparities between the quality and quantity of facilities between India’s northern and southern states are also likely to come to the fore. If the government has plans to deal with COVID-19 infections among children as well, it should pay particular attention to easing hunger and malnutrition.
Venkatanarayanan S. teaches at Andaman Law College, Port Blair. The opinions expressed here are the author’s own.