Intended for healthcare professionals


What will happen to the orphans of covid-19?

BMJ 2022; 379 doi: (Published 07 December 2022) Cite this as: BMJ 2022;379:o2838
  1. David Cox, freelance journalist
  1. Cambridge
  1. dcwriter89{at}

At least 10.5 million children have been orphaned by covid-19. David Cox reports on the global efforts to recognise and secure a future for them

As soon as the covid-19 pandemic began, John Bridgeland and Gary Edson knew that it would leave a hidden toll.

The two former US government officials, who had played an instrumental role in coordinating President George W Bush’s emergency plan for AIDS relief in sub-Saharan Africa, were well aware of the consequences that a deadly infectious disease can wreak on the lives of children. It was the estimated 14.9 million children orphaned by AIDS that they had in mind when co-founding Covid Collaborative, an organisation bringing together experts in health, education, and economics to shape the US response to the pandemic.1

“John and Gary knew early on that there were going to be orphans with this pandemic, both globally and within the US,” says Catherine Jaynes, who leads the collaborative’s initiative to support covid bereaved children. “Since then, we have been working not only with the White House, but members of Congress and key partners on the ground to try to help these families and connect them to resources.”

The collaborative commissioned a 2021 report, Hidden Pain,2 which provided some of the first concrete details on children orphaned by covid-19. To date, there are at least 10.5 million of these children worldwide,3 with studies showing that the burden has fallen heaviest on low income nations. One report in May 2022 revealed that an estimated 40.9% of covid-19 orphans are in South East Asia and 23.7% in Africa.4 Egypt, India, Indonesia, Nigeria, and Pakistan are the five countries bearing the brunt of the crisis.4

In high income nations, it is ethnic minorities that have been hit hardest. The Hidden Pain report revealed that in the US, American Indian, Alaska Native, Native Hawaiian, and Pacific Islander children were four times more likely to have been orphaned than their white counterparts, with Black and Hispanic children two and a half times more likely. The fate of these children will represent some of the most profound long term consequences of the pandemic.

Three decades of research on AIDS orphans has shown that losing a caregiver places the bereaved children at increased risk of abuse,5 as well as mental health problems such as depression, anxiety, and suicide.6 Other long term consequences include higher rates of alcohol and other substance use disorders, worse peer relationships, and reduced employment opportunities, often as a result of dropping out of school.2

But it has also provided years of learning which could be used to establish policies to help.

“We literally have the research to show what works,” says Susan Hillis, co-chair of the Global Reference Group on Children Affected by Covid-19 in Crisis, a non-governmental organisation (NGO) linked to the World Health Organization which was established in July 2021 to develop up-to-date evidence of children affected by covid-19 associated orphanhood. “We have models that we could quickly implement if there were political will at a national, regional, and global level.”

Finding the vulnerable

One of the first challenges is identifying these vulnerable children—and very few countries have an adequate solution.

Five years ago, Brazil, with an estimated 158 600 covid-19 orphans,7 introduced a box on all death certificates which indicates if a child under 18 has been left behind, making it easier for services to check on their welfare. Hillis says that this identification system has already proven invaluable for answering basic questions such as whether the child in question is safe, still in school, and has sufficient food, and could be easily adopted elsewhere.

“There are several countries interested in copying this system,” she says. “For example, I’m going to Malawi and Zambia to meet with government leaders and Unicef to begin to have those discussions.”

Even the US has no systematic way of tracking children who have lost a parent or caregiver. The Covid Collaborative is planning a pilot study in Utah within the next two months, which will aim to use various administrative datasets, such as birth records, to automatically detect whether there are children left behind after someone has died.

“Utah has a significant number of indigenous populations, and we know that American Indians in particular, have been hit hard by this pandemic,” says Jaynes. “We’re choosing a place which allows us to learn how something like this could work, but we hope to expand geographies in the next year or two.”

Securing their future

After finding orphans, there is the question of securing their future. Charles Nelson, a Harvard University neuroscientist best known for his research on institutionalised children in Romania,8 says that it is vital to avoid sending them to orphanages.

“We need to move with alacrity to get these children into stable, supportive environments,” he says. “At all costs we should avoid institutional care and aim for some kind of family care. If a relative isn’t possible, then a permanent family rather than multiple foster care placements. The bottom line is that institutional care derails development, and the longer children remain in such care, the worse the outcomes.”

In India, where there are more than two million covid-19 orphans,9 NGOs are now putting pressure on local governments to release data on the number of children in orphanages, as well as the number who could be legally adopted, which could make it easier for other families to take those children into their care.

Hillis is looking at models around the world in which faith communities collaborate with social services to identify children in need and help find them new homes. She cites the example of Brownsville, Texas, where African American pastors have formed a partnership with the local school and social workers to help covid-19 orphans. “They have years of history of being able to help identify relatives who might be good bets,” she says. “We’re now seeing that collaboration between local government and faith leaders replicated in 27 states.”

But simply relocating these children is not enough. Researchers say there is also an imperative to provide them with sufficient financial assistance to meet their needs. Hillis says that in three quarters of cases, orphaned children have lost their father to the virus, resulting in a substantial income deficit for the family.

“Evidence shows that kin care is the absolute best option for these children,” says Lucie Cluver, professor of child and family social work at the University of Oxford. “But those families are now under extreme stress, and effective policies are cash transfers to help families look after children.”


So far, Mexico, Peru, and South Africa have all committed to providing nationwide monetary support to children orphaned by covid-19 in the form of grants or monthly stipends, while at least 11 states and some major cities across Brazil have either passed laws or are considering bills which promise to do the same.10 Colombia is on the way to incorporating covid-19 orphans specifically into their national child action plan priorities, creating a single national registry for these children and a comprehensive care plan which will include a periodic monetary transfer.

In some particularly impoverished nations like Zambia, however, such is the crisis wreaked first by AIDS and now covid-19 that Hillis is calling on external organisations to step in and provide financial assistance. “Zambia has the highest prevalence of AIDS orphanhood in the world, and it now has 45 800 covid-19 orphans,” she says. “In Zambian culture, neighbouring families tend to try to take care of the children, but there are some communities where the pandemic has decimated the employment options to such an extent that nobody really has the resources to feed anyone other than their own.”

At the same time, researchers are growing frustrated that higher income countries with the resources to do more have yet to commit to specific programmes to help their own orphans. While the UK’s 15 600 covid-19 orphans11 will come under existing NHS social care, there is disappointment that no specific initiatives have been announced to provide these children with targeted psychological support or counselling. “Sadly, we aren’t aware of any specific initiatives planned in the UK,” says Juliette Unwin, a researcher at Imperial College London school of public health. “We would encourage existing schemes to seek out and support these children.”

In California, the state government has allocated $100m to create trust funds, known as baby bonds, which will provide a financial safety net for covid-19 orphans from low income backgrounds, when they reach adulthood.12 However, while the White House has recognised the plight of these children through a US presidential memorandum, no official support plan has been put in place at the federal level.

“We’re pushing the administration to do more,” says Jaynes. “We think that this is a topic that should resonate with President Biden—he lost his first wife and his children were left without a mother. We’re hoping that through President Biden’s State of the Union or his next budget, we can have some language that would provide for some of these opportunities.”

Hillis says it is vital that more countries start investing in more expansive schemes to help bereaved children. “We need to figure out better ways of combining the economic support with psychosocial support.”

“We’re already seeing an Ebola outbreak in Uganda, where mortality is around 50%—half of these victims will be leaving behind orphaned children,” she adds. “And this will happen again.”


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

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