COVID-19′s Still-Urgent Lessons of Structural Inequality and Child Health in the United States

Abstract COVID-19's lessons on structural inequality should have been painful and embarrassing to all of us. These daily experiences of an unacceptable status quo among US children are still with us in a post-COVID America. Addressing the multi-sectoral factors that undermine the nation...s health should remain urgent priorities for all health professionals.


INTRODUCTION
COVID-19 was a brutal teacher worldwide and continues to render its instruction in the wealthiest country in the world. The lessons of death, some in isolation without family farewells, healthcare workers facing danger inadequately protected, and previously unimaginable levels of unemployment and economic loss have been heartwrenching. These tragedies happened in microcosm repeatedly with every new surge in cases across the nation. When it is finally all over, many of this pandemic's lessons will come to light through retrospective research hopefully many of us will conduct. For now it is worth pausing to note what was true in the United States before this pandemic emerged and what will remain true after the COVID-19 pandemic is officially declared over: substantial structural inequalities define some children and adolescents' daily realities and undermine their health.

CORONAVIRUS HAS NOT BEEN A GREAT EQUALIZER -IT HAS LAID BARE OUR INEQUITIES. 1
Structural inequality 2 , 3 is defined by a network of interlocking social institutions and policies that systematically and by default, confers and maintains advantages for some while putting others at disadvantage in their capacities to benefit from the nation's shared resources and opportunities. With forces that are so diffusely and yet insidiously embedded in our lives together that they are essentially invisible to the untrained eye, no one individual actor can be blamed for negative and unequal outcomes.
Results of this structural inequality are predictable, hierarchical, and, over generations, faithfully reproducible by race, ethnicity, gender, class and geography. Especially relevant for those pediatric and public health professionals entrusted with the healthy development of children and adolescents, Russel and Levin 3 point out the following: "These institutions are socializing agents -we learn about ourselves and other people from our families, our schools, our government and criminal justice systems, etc." Hence, we arrived at a crisis like that caused by SARS-Covid-2, and once again, stark racial inequalities in incidence and mortality rightfully become front and center, grabbing the headlines for a time. 4 And yet, the systemic inequality responsible for the unequal burden of this coronavirus' catastrophic effects was there every day in pre-COVID-19 America. That structural inequality is rarely problematized at this scale, especially after panicked headlines of a crisis like COVID have receded.
This discussion asks three questions. First, we explore two aspects of everyday life in America that represent basic building blocks of healthy child and adolescent development: the availability of adequate, healthy food and the availability of safe, high quality, running water. Then we discuss the digital divide of everyday life that predictably leads to divergent, unequal life outcomes for America's children. (Note on terminology: We use COVID-19, the illness, and SARS-Covid-2, the virus, interchangeably.)

QUESTION #1: HOW IS IT WE HAVE CREATED A NATION WHERE, AS IN 2020, IF CHILDREN DO NOT PHYSICALLY GO TO SCHOOL, THEY MIGHT NOT EAT ?
As U.S. cities tried to halt the spread of COVID-19, part of the hesitancy and delay of municipalities and school districts had to do with how children would eat if the schools were closed. 5 , 6 Every day in pre-COVID America, an estimated 29.7 million children relied on the National School Lunch Program (NSLP). 7 This was over half (52.5%) of the nation's school children, and included 29% of White children, 36% of Asian children, 68% of Native American children, 74% of Black children, and 77% of Latinx/Hispanic children. 8 The NSLP provides free lunch to children with family incomes at or below 130% of poverty, and reduced price lunch to children with family incomes between 130 and 185% of poverty. 7 The School Breakfast Prog rams ser ves 11.6 million students each mor ning, with the same eligibility requirements.
During the COVID-19 stay-at-home orders, one special g roup at par ticular risk for not accessing adequate nutrition in the face of lost school lunches and breakfasts was the 8.3 million US children who live in households with at least one non-citizen adult. 9 Families with non-citizen adults have increasingly declined government assistance programs despite their U.S. citizen-children being eligible for such assistance. There are fears of incurring "public charge," despite state and federal government messaging ensuring that seeking food for their children will not be held against them. 10 , 11

QUESTION #2: HOW IS IT THAT, AS IN 2020, WE HAVE CREATED A NATION WHERE THERE ARE NATIVE AMERICAN RESERVATIONS AND OTHER AREAS WHERE CHILDREN AND FAMILIES HAVE NO RUNNING WATER ?
Couched between other announcements during the April 10, 2020 daily press briefing of the Coronavirus Task Force, U.S. Surgeon General, Jerome Adams, MD, MPH, reminded the nation, "We tell people to wash their hands, but as studies showed, 30 percent of the homes on Navajo Nation don't have running water. So how are they going to do that?" 12 This is a harsh reminder of the pre-COVID daily normal for some U.S. children and their families.
Today in America, 1.4 million people do not have access to high quality running water, indoor plumbing (hot water, flushable toilets), nor to sewage systems that take human waste away from their homes to treatment plants. 13 In some cases, sewage mixes with the surface soil in children's backyards. Native American households are 19 times more likely than White families to lack indoor plumbing, including almost one out of three homes on the Navajo Nation reservation, which is the geographic size of West Virginia. 13 In 2019, race was the strongest predictor of whether a household has adequate plumbing, including safe, high quality drinking water. 13 Mona Hannah-Attisha, MD, MPH, the pediatrician-hero, and her colleagues against the denials of local and state public officials, revealed Flint, Michigan municipal water department's cost-savings measures that left many of the children of Flint, Michigan poisoned with lead. 14 Forty-four million people in the U.S. utilize water systems that have serious water violations. The National Resources Defense Council reports that between 2016 and 2019, "race, ethnicity, and language had the strongest relationship to slow and inadequate enforcement of the Safe Drinking Water Act." 15

QUESTION #3: HOW IS IT THAT, AS IN 2020, WE HAVE NOT MADE IT POSSIBLE FOR ALL CHILDREN TO HAVE ACCESS TO RELIABLE, AFFORDABLE INTERNET SERVICES THAT OTHER CHILDREN USE TO LEARN AND COMPETE IN A WIRED 21ST CENTURY AMERICA?
The COVID-19 crisis revealed an inequitable status quo that we will likely return to after the captured public attention of COVID-19 dissipates. As technology continues to develop, new digital platforms and tools are shaping how children are connecting and interacting with the world around them, and how they will learn in and outside of schools. Former President Obama announced with the launch of the ConnectHome pilot program in 2015, "The Internet is not a luxury, it is a necessity." 16 School closure due to the COVID-19 pandemic prompted 56 million students (K-12) to access education online. Despite the improvement of high-speed internet access in the last few years, in pre-COVID-19 America, more than 9 million children still lived without high-speed internet access at home. 17 , 18 Additionally, many did not have the proper devices to access the internet, affecting their ability to complete or turn in assignments in a timely manner.
Pre-COVID-19, Black and Latinx/Hispanic children were more than three times more likely than White and Asian children to access their home's internet only by cell phone, a device whose usage can be interrupted by nonpayment or data usage restrictions and may be shared by multiple family members for this purpose. 18 , 19 The Pew Research Center reported that "one-in-five teens ages 13 to 17 (17%) said they are often or sometimes unable to complete homework assignments because they do not have reliable access to a computer or internet connection," including one out of four Black children and those whose families earned less than $30,000 per year. 20 It should come as no surprise that school districts reported that there were children and teens whose online school attendance during the stay-at-home orders and following had been spotty, if existent at all. 21 Recent college admissions cheating scandals engendered widespread disgust and offended our sensibilities regarding meritocracy and fairness in the academic competition that defines American schooling. 22 But COVID-19 embarrassingly reminded us of the digital divide of everyday life that predictably leads to divergent, unequal life outcomes for America's children. "Fair" is not possible in a pre-COVID-19 or a post-COVID America.

"WE'VE NEVER BEEN IN IT ALL TOGETHER." 23
"We're all in this together" was the feel-good mantra during the period of stay-at-home orders during Spring 2020. Nikole Hannah-Jones, 23 New York Times investigative reporter and MacArthur Genius Award winner asserts, "We've never been in it all together. And we're certainly not all in it together now." COVID-19 was a painful reminder of that.
We were appropriately in crisis mode trying to prevent, for example, the starvation of children and their families during school closures and unprecedented levels of unemployment. As we move back (or forward?) towards a "new normal," several questions beg to be asked: How did we get here to this steady state, this tacitly normalized, daily pre-COVID inequality? Did our nation have an activated plan to remedy the ongoing structural inequality of our pre-COVID daily reality?
We have seen pediatric providers and public health professionals act with great success in reducing the impact of structural inequality in the U.S. In 1997, the American Academy of Pediatrics (AAP) celebrated its successful advocacy in the signing into law of the Children's Health Insurance Program. 24 In coalition with the American Bar Association, and the American Psychological Association, the AAP called attention to the unnecessarily excessive number of out-of-school suspensions nationwide. Infor ming and suppor ting the Obama Justice Department's 2014 call to reduce school suspensions, the number of out-of-school suspensions annually across the nation has plummeted by the hundreds of thousands. 25 , 26 Alongside widespread activism against family separation at the U.S. Mexico border in 2019, former AAP President Colleen Kraft's timely warnings of the dire, possibly lifelong health impacts on infants, children, and teens of this trauma likely played a major role in exposing the cruel implementation of this policy. 27 These previous pediatric research and health efforts dismantling or mitigating the effects of structural inequality demonstrate that we can bring that passion and effective efforts to bear on the impact of structural inequalities potentiated by COVID-19. Indeed, the AAP has begun to engage the issues as they have in their past successes, with their guidance for reopening schools. This guidance is based on their argument that "[ b ]eyond supporting the educational development of children and adolescents, schools play a critical role in addressing racial and social inequity. As such, it is critical to reflect on the differential impact the COVID-19 pandemic and the associated school closures have had on different racial and ethnic groups and vulnerable populations. The disparities in school funding, quality of school facilities, educational staffing, and resources for enriching curriculum between schools have been exacerbated by the pandemic. Families rely on schools to provide childcare; a safe, stimulating space for children to lear n; oppor tunities for socialization; and access to school-based mental, physical, and nutritional health services. Without adequate support for families to access these services, disparities will likely worsen, especially for children who are English language learners, children with disabilities, children living in poverty, and children of African American/Black, Latinx/Hispanic, and Native American/Alaska Native origin." 28 Changing the pre-COVID-19 reality for half of U.S. children who depend on school to stave off hunger and malnutrition, families across the country need a living wage. Especially as we now (finally) recognize their parents as "essential" workers, it makes sense to re-commit to the creativity and advocacy required for the removal of barriers to economic success and wealth-building for all American families.
We should hold publicly accountable federal, state, and municipal governments for completing water delivery and waste treatment systems to all Americans, especially Native American reservations, in California's Central Valley, Texas border towns, and numerous other rural communities. 29 Indeed, the very existence of Native American reservations reminds us of the nation's theft of the most arable, irrigatable land, now inhabited and enjoyed by many of us. 30 This health-stealing structural inequality may be less complex to resolve than we think. George McGraw, CEO of DigDeep water advocacy g roup, repor ts that in 2015, the organization installed cisterns and electric pumps, bringing hot water for showers and the tap for over 200 homes on the Navajo Nation at the relatively paltry price of $4000 per household. 29 Making basic broadband freely available to all families, as it incompletely had been during the COVID crisis, not only enhances children, teens, and our nation's competitiveness in the 21st century economy. The continued provision of free broadband at a basic level also goes a long way to supporting what has now become a critical part of holistic child and adolescent development in a wired society.
It is past time to move forward to a 21st century reality in the United States where we can truly all "be in this together," addressing the structural inequalities that daily undermine the foundations of child health. Recently, in specific reference to racial injustice, Fuentes-Afflick has poignantly and rightly called for not only "innovative, widespread societal action," but also "a complex, multifaceted series of strategies and tactics… and more research to develop and test interventions" that will lead us to health equity and to what she calls an "equity culture in pediatrics." 31 Racial and other structural inequalities are part of the status quo that defined pre-COVID and today's America. It is possible that the routineness and dailyness of their reality has shocked us, embarrassed us even. That would be a good thing. We should pursue the dismantling of these social determinants of health with more urgency as we arrive at or back to a new "normal." Optimal and equitable population health requires that we relentlessly interrogate "normal" through research and policy discussions, proactively transfor m "nor mal," and design, accelerate and evaluate efforts at dismantling structural inequality in our nation's daily reality, on behalf of many American children, teens, and their families.