Pediatricians have long recognized that social determinants (the circumstances in which children live, learn, and play) influence the health and well-being of children and their families. The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of this broader scope of health care, which encompasses more than simply addressing a child’s medical conditions. Although the vast majority of COVID-19 cases in children have been mild, the secondary effects on the health of children have been profound. Downstream effects of the virus on a family’s social circumstances, including increased food insecurity, housing instability, school closures, and lack of child care, have exacerbated preexisting socioeconomic and racial disparities. Although it has often been overlooked, the need for safe and enriching child care that allows parents to be able to work, particularly for the most vulnerable children in our society, has become more acute over the last several months and requires urgent action.
The pandemic has brought to light the lack of safe, reliable, and affordable child care options. Even before the closure of many facilities, child care was plagued by long waitlists, ballooning costs, and safety concerns. Child care costs for preschool-aged children can rival college tuition, making high-quality child care nearly inaccessible for many families, especially those experiencing material hardships. With recent school closures due to COVID-19, even older children now require supervision throughout the day. As such, parents have been forced to consider child care arrangements that may not best align with the needs of their family. This includes taking parents (predominantly women who face the disproportionate burden) away from work or calling on family members and friends to oversee the care of their children, perhaps risking their health or the health of others. Simply put, safe and reliable child care is an essential for economic and social recovery and subsequent stability.
Securing child care is particularly challenging for low-resourced families, including those with children with chronic health conditions, those with parents who work nontraditional hours, and those in non–English-speaking households and in rural areas. At urban community health centers, one study found that nearly one-third of families had an unmet child care need, and this was before any coronavirus effects were present. Today, many essential workers are from lower socioeconomic strata and must continue reporting to work in person, lacking flexibility to arrange for the around-the-clock child care now needed. Unfortunately, it is these same communities in which child care facilities see decreased revenue because of community financial instability and therefore run the risk of closure.
Pediatrics as a field has moved to more formally screen and address specific social determinants of health, including food insecurity and housing instability.1,6 Thus far, however, child care has not been a focus of large-scale, practice-based interventions or public policies. Although policy solutions have emerged to combat housing instability, unemployment, and food insecurity worsened by this pandemic, child care has lagged behind. We believe child care is a social determinant of health that crucially impacts the health, development, and economic well-being of children and families and that, as pediatricians, we have a duty to help address this prevalent need. Surveys during the pandemic have revealed significant challenges in child care availability for both high- and low-income families, further emphasizing this gap. Given this context, we make the following recommendations.