Jan 23, 2021 Volume 397 Number 10271 p253-346, e3-e5
COVID-19: the intersection of education and health
What lessons does the COVID-19 syndemic offer when considering the convergence between health and education? The International Day of Education, on Jan 24, provides an opportunity to reflect on the weaknesses of the education system before COVID-19, and on the impact of school closures and education disruptions on children and adolescents. Since March, 2020, more than 1·5 billion students worldwide—an unprecedented number—have been affected by school or university closures. The implications of these closures are enormous. In addition to the loss of learning, a lack of access to school means that many children lose protection from hazards such as domestic violence and child abuse, others lose access to the only nutritious meal of their day, and many will miss immunisations that are often given at school. Furthermore, school closures deprive children and adolescents of social and emotional experiences essential for their development and wellbeing.
Adolescents are particularly affected by both closures and by distance learning in higher education. In the short term, some students are leaving school to find work earlier than they might otherwise have; others might be experiencing mental health problems such as loneliness and anxiety. In the long term, there is a danger that hard-won progress in secondary school attendance in low-income and middle-income countries will be reversed. And it is not only schools that shape education. Cultural events, sport, and religion have been disrupted, in many countries for almost a year. Under lockdowns, children who have not yet reached school age have been forced to remain at home, and low levels of stimulation during a child’s early years are likely to have far-reaching consequences for their development. Health and education are bidirectionally linked: a good-quality education is an investment for health, and health is essential for effective learning. These disruptions to education, and the subsequent widening of inequalities in learning, will adversely affect the health of this generation and their children.
The disproportionate effect of school closures on girls and poorer students is especially concerning—millions of children are predicted to drop out of school (the humanitarian analysis organisation ACAPS says 24 million; Save the Children estimates 9·7 million). Many educational institutions have re-established their programmes online to mitigate short-term interruptions in learning. However, the effects of a digital divide and intangible losses of cognitive and social skills cannot be easily repaired. The economic crisis is pushing poor households into greater poverty, with families turning to early marriage as an alternative form of income. This predicament further perpetuates intergenerational poverty and inequality. Education is the only ladder out of poverty for many children and adolescents, and it is crucial to empower girls to economic independence and resist violation of their rights.
Education systems will be most beneficial when they provide more than a curriculum in science, maths, languages, and other academic subjects. Programmes that better support the cognitive and behavioural skills of children—self-reliance, decision making, anxiety management, communication, and assertiveness—will enable them to thrive. Traditional educational skills need to be expanded to encompass training in sexual and reproductive health and rights, child nutrition, and mental health.
This conceptual change in the value of education needs to start at the national level with revitalised education programmes. There is evidence that holistic approaches to education that value health and wellbeing can be effective. But their success is dependent on the political will to implement and support them. For example, the Health Promoting Schools approach developed by WHO values schools as social communities inclusive of students, teachers, and families; however, WHO reports that few countries have successfully implemented it at scale. This approach is aligned with the Sustainable Development Goals (SDGs) for health (SGD3) and quality education (SDG4), which explicitly acknowledge the linkage between health and education. Yet, the two sectors remain distant; arguments over whether to close schools to prevent infection can even imply that they are in opposition. This disconnect needs to be remedied. Closer cooperation would revitalise not only education, but also child and adolescent health.