There are always fresh flowers on Langlang Buana’s grave in the small town of Pasaman in the Indonesian province of West Sumatra. His youngest daughter, Yuni Folani, known as Ivo, passes the cemetery on her way to school. She visits so often that the petals she plucks from the bougainvillea in her front yard are still fragrant when she returns with a fresh bouquet.
Her father died of kidney failure while ill from COVID-19 last year. The younger of his two children, 14-year-old Ivo recalls she and her dad teased each other constantly and were inseparable. She wants to be a policewoman when she grows up, following in the steps of her father, who was a security guard. “I really miss him getting mad at me,” Ivo says as tears stream down her face.
Without him, the family has fallen on hard times. Ivo’s mother, Nisma, is the only breadwinner, struggling to stretch the hundred dollars she earns each month at the local grocery store.
Ivo and her family are far from alone. The World Health Organization estimates that as of May 5, nearly 15 million people have died of causes related to COVID-19 since the global pandemic hit—almost three times the official death toll. In the United States, the country that has recorded the most deaths, nearly one million Americans have died, according to data compiled by Johns Hopkins.
Hidden behind those statistics is an orphanhood crisis unprecedented in modern history. Nearly 10.4 million children worldwide have lost a parent or caregiver to COVID-19, according to latest estimates from Imperial College London. In the U.S., more than 214,000 children have lost a parent or caregiver. Like the death toll itself, the true numbers are likely higher.
Bereavement is life-changing for anyone, and particularly devastating for kids. Decades of research show that losing a caregiver puts children at increased risk of abuse, poverty, and mental health problems such as depression, anxiety, and suicide. If kids don’t get adequate support—or if their hardships are particularly severe—the stress can even change the architecture of their brains and leave them more vulnerable to every major cause of death, says Susan Hillis, co-chair of the Global Reference Group on Children Affected by COVID-19, a partnership between the University of Oxford and the World Health Organization.
COVID-19 also has fomented conditions ripe for chronic stress as children face lockdowns, school closures, and the constant threat of losing more loved ones. But Hillis and other experts say it doesn’t have to end in catastrophe: Lessons learned from past health crises teach us how to help kids cope with the unthinkable.
“It’s going to take all of us working together in a way we haven’t,” she says. What’s critical is to act quickly.
The trauma of orphanhood
People tend to think of orphans as anyone who has lost both parents. But the United Nations defines an orphan as a child who, like Ivo, has lost any parent—and, increasingly, the term has come to include grandparents and other caregivers.
“Whenever you’ve lost one parent, to some degree you’ve lost both,” says Carolyn Taverner, co-founder and program director of Emma’s Place, a grief center for children and families in Staten Island, New York. Surviving parents are grieving themselves, and many have less time to tend to their children as they attempt to keep everything together. Kids are also remarkably attuned to their parents’ emotions—and often tend to protect their parent by hiding their own feelings.
This toll of orphanhood became clear early in the AIDS pandemic, which according to a Joint United Nations Programme on HIV/AIDS report left behind 903,000 children globally in 1990, the first year estimates were made. In the decades since, researchers have amassed a strong body of evidence of the risks of losing one or both parents or caregivers.
It starts with mental health. Taverner says the loss of a parent is often the first time a child realizes bad things can happen at any time. Younger kids who haven’t learned yet how to cope with their emotions tend to have more outbursts and may have trouble at school. Older kids, whose friends may not understand their loss, begin to feel isolated in their grief.
But children also face other dangers to their health. The loss of a breadwinner can plunge a family into poverty, leading to malnutrition or forcing kids to drop out of school and work. Research from the journal Vulnerable Children and Youth Studies among others shows that children who have lost a parent are more vulnerable to physical, sexual, and emotional abuse.
“You have this constellation of abuses or adversities piling up on the individual child,” Hillis says.
That pile-up can result in a condition called toxic stress. Typically, the body deals with a taxing situation by sending the heart racing and flooding the body with stress hormones. When those conditions are prolonged or severe, the body can experience a cascade of harmful biological responses—including impaired neuronal synapses of the brain.
Toxic stress can put a child at risk for long-term complications such as diabetes and Parkinson’s disease. It also can damage the immune system’s ability to fight off disease, and increase the risk of dying from heart disease, HIV/AIDS, and more. Orphaned children are also at higher risk for suicide.
In January, UNICEF reported that more than 616 million students worldwide are still affected by COVID-related school closures, which experts worried could push the world’s most vulnerable kids into child labor. Missing school is also harmful for grieving children who take comfort in their routines.
“Once the pandemic hit, there was nothing that was the same,” Taverner says. “There’s nowhere you can go to escape it.”
A hidden catastrophe
The pandemic hadn’t yet hit Zambia in spring 2020, but Remmy Hamapande worried as he watched COVID-19 ravage the world. As country director of the nonprofit Forgotten Voices, which works in several countries in southern Africa, Hamapande knew a deadly pandemic would be dire for children there who had already lost their parents to AIDS and were living with grandparents who were especially vulnerable.
“If COVID comes here and takes out the grannies, we would have no one left to care for the orphans,” Hamapande recalls thinking. “Then these orphans become orphaned twice.”
Hamapande called Hillis to raise the alarm. During her decades-long career as a researcher at the U.S. Centers for Disease Control and Prevention, Hillis studied children orphaned by health crises. By August 2020, she had convened a team of researchers to assess how many children were affected, beginning with the United States and Brazil.
In just two weeks, preliminary data “was shocking and heartbreaking,” Hillis says. For every two reported COVID-19 deaths in those countries, estimates suggested at least one child was left behind. As the Delta variant drove surges across the world, that number grew to one orphan for every COVID-19 death—and two orphans for each death in Africa as of the end of October 2021.
Despite the staggering losses, the COVID-19 orphan crisis has gotten relatively little attention; it’s a pandemic hidden inside a pandemic. Rachel Kidman, a social epidemiologist focused on childhood adversity at Stony Brook University, says COVID-19 is perceived as a disease affecting older people, so the toll on children left behind is overlooked.
Yet as many as 38 percent of children globally are raised in multigenerational households, according to the Pew Research Center. In Zambia and much of the rest of sub-Saharan Africa, more than 30 percent of children live in “skipped-generation” households—meaning they live with grandparents, not parents.
Moreover, Kidman points out that COVID-19 is not just killing grandparents. The uneven distribution of COVID-19 vaccines has left people of all ages more vulnerable in some parts of the world, and it’s disproportionately fatal for people with poor access to healthcare.
“There are now substantial numbers of people below 65 who have passed away due to COVID. Those are people who are in parenting years,” Kidman says.
In Zambia, Hamapande has seen siblings split up and villagers struggling to feed their own families who have taken in children of neighbors. Counseling is virtually nonexistent and Hamapande has seen signs of trauma from bed-wetting to a spate of suicides.
“Imagine a child losing their caregiver and then basically not having anywhere to run to,” he says, adding that mental health assistance is desperately needed.
How to protect orphaned children
Past crises have taught scientists what may work, and what doesn’t, to soften the trauma.
One thing not to do? Put children in orphanages—or at least not the facilities where neglected kids are packed in like sardines. Landmark studies of Romanian orphanages—which became notorious in the 1990s for their deplorable conditions—found institutionalization significantly altered infants’ brain structure. Every year in an orphanage resulted in developmental and cognitive delays compared to children raised in foster families.
Fortunately, these effects can be mitigated if a child is moved into a loving home. In 2012, one study showed that children who moved from orphanages to foster families were able to catch up developmentally with their peers.
Children need family—of any sort—to provide structure in their lives, says Lucie Cluver, a professor of social work at both the University of Oxford and University of Cape Town. Ensuring that a child can go to school, has enough to eat, and feels loved is what “determines the impact of the death, not the death itself.”
Even orphans who are well cared for need extra help. Cluver, who was part of the team Hillis convened to determine global estimates for COVID-19 orphans, says the top three interventions that make a difference are economic support, parenting support, and staying in school.
Making sure families have enough money and food is fundamental. When parents aren’t working multiple jobs, they have time to listen to and support their kids. When children have enough to eat and can stay in school, they’re less vulnerable to other risk factors. Giving money to impoverished families has been shown to significantly decrease the risk of girls and young women being forced into or resorting to sex work for payment.
Abuse is another risk. Parental stress can lead to violence in vulnerable families, and arming caregivers with practical coping skills is critical when grief causes a caregiver or a child to act out. Studies have shown that parenting programs can significantly reduce physical, sexual, and emotional violence in families.
Finally, it’s important to make sure that orphaned children can still go to school. Attending school helps traumatized children regain a sense of normalcy. It’s also proven to reduce poverty, delay a child’s first sexual encounter, and integrate them into society.
Is help on the way?
In late September 2021, Calandra Cook was a month into her senior year at Georgia State University when she suddenly had to withdraw to plan her mother’s funeral. With no other close family to help, the 21-year-old was suddenly responsible for everything, which she did in a daze.
Doctors had warned Calandra that her mother’s lungs were getting weaker, her heart rate was too high, and her oxygen levels were too low. But Yolanda Meshae Powell’s death still came as a shock to Calandra and her three younger siblings, who couldn’t talk to or even hug their mother before she died. “I had to say goodbye to my mom through a glass window,” Calandra says.
Then came the daunting challenge of finishing college. Georgia State’s financial aid office informed Calandra that she’d exhausted her student loans and would have to pay out of pocket—and she couldn't move back home to save money.
“When my mom died, my safety net died with her,” Calandra says.
Earlier this year, the COVID Collaborative—a group of leading U.S. experts in public health, education, and the economy—established Hidden Pain, an online platform that connects grieving families to resources including funeral assistance, discounted internet service, and bereavement and mentoring groups. In California, lawmakers are considering a state-funded trust fund for COVID orphans. But there’s been little movement at the national level.
The world also has yet to act to help orphans on the scale that was seen under PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief. It took 13 years to enact PEPFAR after researchers first raised the alarms about AIDS orphans—and, by then, 903,000 AIDS orphans had grown to 15 million.
“I’m just hoping and praying we don’t wait 13 years,” Hillis says. “This tsunami is going to envelop us as variant after variant emerges.”
Calandra is frustrated that the world seems to have moved on from the pandemic—even the people who had comforted her when her mother first died. “As time goes on, people go away,” she says. “Grief is something you kind of deal with on your own.”
She’s still finishing up her coursework, but she will be walking alongside classmates at their commencement ceremony in May—on Mother’s Day weekend, no less. It’s a bittersweet milestone: Yolanda was so excited for her daughter to get a degree that she used to call her three times a day to gush about it.
Calandra knows it’s going to be hard to walk across that stage on graduation day without her mother in the audience. “People say that she’ll be there in spirit but that doesn’t make you feel better,” Calandra says. She’s going to take some of her mother’s favorite advice. “I can hear her telling me to put my big-girl panties on. My mom taught me everything.”