A good friend recently invited me to meet his spiritual guide via Zoom. The spiritual guide does energy work, which he claims requires no physical proximity and works based on principles of Christianity and quantum mechanics. After some introduction of his methods, the spiritual guide turned his attention to me, rotating a small wooden bar in the air and snapping his fingers against his hand in order to confer on me protection from the novel coronavirus. I could see his living room behind him, and his wife joined from a separate device elsewhere in the apartment.
The procedure was brief, and shortly he pronounced me protected. “Is the baby protected, too, Lord?” he asked. There was a scant pause and then “Amen,” he said, “the baby, too.”
Humiliatingly, I started crying. I could not explain it in that moment, so I allowed my friend to believe that I cried because of the power of being conferred such protection. I exited the Zoom, thanking them both, and snapped my laptop closed.
The fact is I was crying because I know there is no way to guarantee safety for my baby, who, at thirty-seven weeks, rides in my uterus through the hospital daily, while I work as a pediatric hospitalist and the pandemic blossoms here in Texas. Nobody can say to me—or to any parent, at this point—what exactly will protect the little bodies that pertain to us.
This has always been true, and more pointedly so for some parents than others. To have ever believed one could keep a child safe in this world is a marker of privilege, generally reserved for affluent white parents such as myself. Yet I have never been asked so often or so fruitlessly what specific formula might confer protection on the children: if they have playdates but only with one neighbor, if they go to the park and wash hands afterward, if they start school but in the school everyone wears masks.
I tell parents about the data that supports their hope to safely liberate children from home. Though it was initially reasonable to suspect that SARS-CoV-2 would behave like other respiratory viruses and use children as the little viral culture media which God created them to be, evidence is accumulating that, so far, children are not the primary drivers of this particular pandemic. They absolutely do get sick from it, and many, around one in two hundred in some studies, get so sick that they require I.C.U.-level care. But the most frightening manifestation of SARS-CoV-2 infection in children—multisystem inflammatory syndrome in children, or MIS-C, which often lands them in I.C.U.s but rarely seems to kill them—remains rare.
I have my own fears about infection, however. So far, the diagnostic criteria for MIS-C require proof of current or recent infection with (or documented exposure to) the novel coronavirus. Most cases seem to be occurring two to four weeks after infection. But the inflammatory sequelae of other viruses, such as measles, herpes, and chicken pox, may occur years after infection. As many as one in twenty children infected with measles will develop pneumonia, and around one in a thousand develop encephalitis: swelling and inflammation of the brain. A much smaller percentage (two in a hundred thousand) will develop subacute sclerosing panencephalitis (S.S.P.E.) generally seven to ten years after measles infection. This slow, inflammatory scarring of the brain is fatal. Just as we do not yet know what, if any, long-term complications may lie in wait for children infected with SARS-CoV-2 in utero, we do not yet know if this virus will carry any super-delayed sequelae of childhood infection.
Sometimes I think that the habit of mind that most clearly separates experienced physicians from faith healers is not scientific rigor but prudence. We physicians have seen enough irremediable suffering to know the limitations of our art. We are acquainted with fortuna, the capricious force of destiny that deals suffering and healing without regard for our efforts. We promise to work through the night for our patients, to explain every step, to be at their sides no matter what. We do not, however, promise safety. Even when I am caring for a baby with a very routine respiratory infection, I do not promise parents that their child will recover. I say, “We’ll help your baby by giving her the extra oxygen, and we will watch her very closely. If we see that she’s getting sicker even with the oxygen, then we’ll talk to the I.C.U. doctors about the next steps to keep her safe.” I know a lot of science, but I also engage with fortuna and a level of magical thinking that would be more appropriate in a four-year-old; I can’t escape the fear that some horror will befall any baby whom I promise an easy recovery.
In the case of the novel coronavirus, prudence tells me that I should be at least as worried about actual measles and S.S.P.E. as I am about theoretical risks of long-term sequelae of SARS-CoV-2. Worldwide, childhood-vaccination rates are declining and measles outbreaks are blossoming amid the coronavirus pandemic. I should also worry about children losing their parents or grandparents, missing meals, and falling behind in school. I should worry about kids whose learning disabilities will go undiagnosed without school screenings, L.G.B.T.Q. teens trapped in unsafe homes, and children traumatized from witnessing domestic violence. When my friends ask me how to keep their kids safe, though, they mean safe from infection. I refer them to the guidelines of the C.D.C.
I get the sense, though, that parents don’t want my prudence; they want my blessing. They want to move out into the world under the glimmering umbrella of a pediatrician who has said, “Amen, the child is safe.”
Early in the pandemic, the number of children admitted to my hospital fell. Kids were staying home and avoiding the usual respiratory viruses that drive hospitalization; when kids did get sick, parents were likely avoiding the hospital for as long as possible.
With fewer sick kids, the service was dominated by trauma. We saw plenty of injuries related to neglect: kids burned from having poured gasoline on fires while unsupervised, or shot from playing with unlocked guns. Then there were the abuse cases: children with brain bleeds from abusive head trauma, or liver lacerations from being pummelled in the abdomen. Although my hospital has not published data on these cases, pediatricians across the country are worried that abuse is on the rise. Educators are often the people who detect early signs of child abuse and neglect; with schools closed and fewer cases of suspected maltreatment being reported, some doctors are seeing more severe trauma among children.
When a child comes in with an injury that could be from abuse, we pediatricians go looking for other injuries. We may do X-rays to look for evidence of old broken bones, or a scan of the head to look for bleeds. We may draw blood to look for evidence that the liver has been injured by blunt trauma. We look for characteristic bruises and patterned scars. Sometimes these investigations reveal a long history of physical abuse. These are the children who keep pediatricians up at night: kids whom we probably saw in the office or in the hospital for a so-called sentinel injury—an early, less serious injury that was caused by abuse but went unrecognized. In one study of infants hospitalized for serious physical abuse, just over twenty-seven per cent had a previous sentinel injury, and nearly forty-two per cent of those were reportedly evaluated by a physician.
Most kids hospitalized for abusive trauma, however, had no known sentinel injury. Researchers sometimes describe pediatric physical abuse—especially abusive head trauma—as an impulsive event: a parent or caregiver, frustrated by an infant’s persistent crying, picks up a baby and slams the child’s head against a hard surface. The pandemic could worsen both systematic and impulsive child abuse. Kids who were never safe at home are trapped there now, while many parents who cared for children responsibly before are facing new levels of stress—stemming from illness, job losses, looming evictions, lack of child-care support, cramped living conditions, and more—that could trigger impulsive abuse.
To acknowledge that social conditions contribute to mistreatment of children is to court a strange compassion—a whisper that more of us might come closer to hurting children than we prefer to admit, if the conditions were right (or wrong). It’s uncomfortable, but true: children are more vulnerable to abuse when their families are under stress, and children who live in poverty are more likely to be neglected or abused. Whereas one in eight children will suffer a confirmed case of abuse or neglect by age eighteen, kids whose families are struggling economically are more than three times more likely to be abused and around seven times more likely to be neglected than economically secure peers. Kids under one year of age are far more likely than older children to be neglected or abused; they are also more likely to be killed by caregivers.
We are all too quick to think of child abuse as a matter of viciousness alone, and I worry that pointing out higher rates of abuse among impoverished children will lead to further stigmatization of poor and working-class parents. But that narrative, that the poor abuse their children because they are vicious, must be corrected. The stress of poverty depletes cognitive and emotional resources, which can lead to harsher, less emotionally responsive parenting. From the child’s perspective, of course, it is all fortuna: we are each born into a single life, and don’t realize until much later that other lives are possible, or that the adults responsible for a child’s well-being—parents, communities, government—might have built safer and kinder worlds, but didn’t. The converse of poverty begetting neglect and abuse is that good parenting cannot be understood as mere virtue: rather, it is a goal that policy can support.
Specifically, we can prevent child suffering by using money to directly ameliorate child and family poverty. The earned-income tax credit, for example—a benefit for working families with low or moderate incomes—has been the single most effective initiative for reducing child poverty in America. It lifted three million children out of poverty in 2018, and reduced the severity of poverty for 6.1 million more.
A few important studies have been able to show that money given to poor families directly improves child health. For example, Dr. Jane Costello, of Duke University, and her colleagues found that children’s health in both the short and long term improved when Cherokee families on a reservation in North Carolina started receiving subsidies from a local casino. In this “natural experiment,” adult members of the Tribal Nation received direct payments of approximately four thousand dollars, beginning in 1996. Kids who were lifted out of poverty by the supplementary income had the greatest benefit, with reduced behavioral problems, higher school achievement, and lower rates of substance abuse in adulthood.
Costello and her colleagues have argued that these benefits work in part via improvements in parenting: money in the household reduces stress, which leads to better parenting. Good parenting, in turn, profoundly influences child resilience and child health. To flourish as a parent is not merely a wish. It is not an act of will or of individual goodness; it is a social outcome that policy can support, and which we must put at the forefront of all policymaking if our society is to survive this pandemic with something left to cherish. As of this writing, however, Congress has not yet acted to extend one of the few and most straightforward benefits offered to financially strapped families since the pandemic took hold: the six-hundred-dollar weekly supplement to unemployment insurance, provided as part of the CARES Act, that is set to expire on July 31st. Even those who are discomfited by the idea of giving money directly to unemployed people should acknowledge that the stakes of withholding that money will be measured in my hospital, in beds that fill with the bodies of children whose suffering we could have prevented.
In the ninth month of pregnancy, I find myself living and working in a coronavirus hot spot. San Antonio ranks in the top ten nationally of cities with the highest growth of new cases, and the pandemic now threatens to fill our hospitals and I.C.U.s. This was not what the models predicted, but of course we had a late and partial shutdown, followed by an apparently premature reopening and now another partial shutdown. In June, Governor Greg Abbott moved to shut down bars and commercial tubing: floating down a river in a rented inner tube, which is a wonderful thing to do, and how I would have spent much of my last trimester of pregnancy in a world that is not reachable now.
I am a fifth-generation Texan, led by yahoos at the state level since Governor Ann Richards was ousted by George W. Bush, in 1994, and it does not surprise me that our state politics defies mathematical modelling. Like medical practice, being a liberal Texan acquaints one with the machinery of fortuna: terrible things happen to nice people, and I have never suffered the delusion that I was in control. Justice is possible—and good health policy can still save Texan lives—but the feeling one gets on the ground is of being whipped by fate.
In an attempt to protect me from infection as much as possible, my boss has moved me from the pediatric wards—where I usually care for kids sick enough to need hospitalization—to the newborn nursery, where I care for healthy new infants.
“How far along are you?” a mother asks when I belly up to her newborn’s crib.
“Thirty-seven weeks,” I say.
“Almost there,” she says, smiling at me. I like the way that my pregnancy rattles the exchanges in the nursery. The mothers I care for have gone through something I haven’t, and they try to reassure me that I, too, will come through safely, with a healthy child.
“Yup, I’m just planning to walk over to the L. & D. when he starts coming,” I say, and we both laugh. The nursery is one of the few places left in the hospital that has not been much disrupted by the virus. We do test laboring mothers, and those who are positive for the virus are put in isolation. Only one birth companion is allowed for each delivery. Where once I would encounter whole families clustered in a nursery room passing the baby from hand to hand, now the rooms are quiet, with space to move. New parents want to leave as soon as possible. Here, if it weren’t for the overhead code calls that make me catch my breath until I hear the word “adult” and know I don’t need to set off running—here, you could almost imagine that breastfeeding and the perfect swaddle are enough to keep children safe.
Even though my colleagues are protecting me from the worst of it, I have come to think of my particular body as a vector: because I go to the hospital, I am at higher risk than others of being infected. Even if I don’t care for known COVID-19 cases, as a pediatrician I spend time in rooms with people who have not been tested for the disease—my colleagues and the companions of those who have come to give birth. The grandmothers, the dads, the non-birthing mothers—all together, they account for a large epidemiological web. Only once in the last six months of my pregnancy have I gone more than two weeks without being in the hospital, and I seized that window of presumptive health to see my own parents. Otherwise, pregnancy has been a lonely stand: I cannot in good faith see the people I love, knowing that seeing me puts them at risk. My doctor body, meant to stand for safety and cleanliness in its long white coat, is dangerous.
Yet my husband and I have this wonder coming to us: a birth. And, for me, a few weeks of respite, a clean turn away from the code calls ringing out overhead and the spectre of refrigerated trucks. A chance to stop thinking about all the children, and focus on one—this kicking creature, this small leviathan within, who stubbornly insists on life amid so much death. Of course, nobody knows what pregnancy will bring until the end (or perhaps ever) and—fortuna, fortuna—I have seen it go all wrong at the very last minute, women ashen and still bleeding outside a resuscitation room while we push another round of epi into a child whose heart won’t start, young widowers weeping beside an incubator. It should have been me, not her, a new father once said to me in a room like that, grappling at that old wish to take the beloved’s suffering into one’s own body, to transmute death for death. I know death comes to the nursery, too, if rarely from the coronavirus.
Even so—and magical thinking makes this nearly impossible to type—I feel a beginning is near. I feel that this child will open his eyes, that he will breathe and cry and go home with me around day two of life, that he will grow and walk and perform all those acts which the everyday horrors of my profession make seem miraculous and which are even more miraculous just now. I feel I might just be permitted to wrap him in a blanket and bear him far away past the pronated, gasping grandparents, even with all I know as a physician, with the pandemic, with the pale horse and her pale rider galloping the warm winds of my city, even so, I might just be permitted to believe this time, for just this once, that the baby will be healthy. That he will be safe.
More Medical Dispatches
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- It is not too late to go on the offense against the coronavirus. This five-part public-health plan may be the key.
- The loneliness and solidarity of treating coronavirus patients in New York.
- To fill the vacuum left by the federal government, doctors are relying on informal networks to get the information and support they need.
- Conflict and confusion reign at New York hospitals over how to handle childbirth during the pandemic.
- In countries where the rate of infection threatens to outstrip the capacity of the health system, doctors are confronting ethical quandaries for which nothing in their training prepared them.
