In a new study published in the Lancet, our team presents a simple, yet surprising finding: one of the most direct and immediate harms posed by the COVID pandemic to children is death—specifically, the death of a loved caregiver such as a mom, dad or grandparent. The consequences of orphanhood, defined as occurring when a child has lost a mother, a father or both, can last a lifetime. As the world passes the grim milestone of four million reported COVID-19 deaths, our study reveals that 2 million children at a minimum have been directly affected by this hidden pandemic.

The profound, sudden and global loss of parents and grandparents is a tragic pattern emerging in the modern era—first HIV, then Ebola and now COVID-19. In our study we estimate that one in a hundred children in Peru, four in a thousand in South Africa, and one in a thousand in the U.S. lost a parent during the pandemic. The overall numbers are shocking as well: through early July 2021 at least 1.5 million children lost a parent, and two million children lost a parent, grandparent or relative who lives with them and is involved in caring for them. (While our study period ended in April 2021, we have built an online calculator to give up-to-date estimates and an Our World in Data–style visualization of orphanhood trends over time.) As the pandemic has accelerated, so too have the overall numbers: orphanhood has doubled globally in the first half of 2021 as compared to all of 2020.

How did we reach our estimates? We start with data on COVID or excess deaths, broken down by age and sex for 21 countries comprising almost 80 percent of worldwide COVID deaths. We then combine this death data with fertility data to calculate the number of children left behind. To calculate orphanhood, we focus on adults who might be parents using the average number of children a man or woman of different ages has for each country. From this, we work out the following: if an adult of a certain age dies in a given country, how many children on average would be without a parent? 

We also consider the loss of grandparent caregivers, using estimates on the number of grandparents who live with and provide primary care for their grandchildren. In both cases, we are able to obtain a country-specific ratio: how many children on average experience orphanhood for a single death? This ratio varies widely between countries based on family sizes: in the U.S., for 100 deaths during the pandemic, on average 13 children experienced orphanhood. In Italy, with smaller families and older populations, the ratio is 100 deaths to two children experiencing orphanhood. Countries with larger family sizes and younger populations will have higher ratios: Peru’s is 100 deaths to 41 children, while Nigeria’s is 100 deaths to 189 children.

As high as our estimates are, they are only lower bounds, that is, minimum estimates, because we largely rely on COVID-19 death reporting, which could be a significant undercount. Important research on excess deaths from a number of institutions suggests that the four million reported COVID-19 deaths might equate to as many as 10 million true deaths. We use reliable estimates of excess deaths where possible, but we could still be underestimating orphanhood by a factor of two. Another issue is that our estimates are based on simplifying assumptions as we cannot account for important demographic and epidemiological patterns. We do not take into account, for example, the association between low income and large family sizes. Essential workers and the poor in many countries are more exposed to the novel coronavirus, die from COVID at higher rates and thus leave behind more children.

Since COVID often spreads within households, larger families are also more likely to have higher exposure. Our estimates for children whose grandparents have died are likely to be undercounts as well, because we do not account for the fact that a grandparent who lives in a multigenerational household providing care for grandchildren has more exposure than an adult of the same age who lives alone.

Tragically, while our estimates—minimums that they are—shed light on this neglected dimension of the pandemic, the children behind these numbers remain hidden, because death records do not routinely record dependents. No country we are aware of has undertaken a comprehensive census or survey to find these children. To be sure, the pandemic poses logistical problems for safely carrying out reliable surveys. Nevertheless, many surveys and censuses are being carried out in high- and low-income countries alike. We call on governments and statistical authorities to begin to measure the scale of this problem and provide support to families and communities.

Make no mistake: we must not let these children be institutionalized in children’s homes or orphanages. Groundbreaking research by one of the senior authors on our study, Harvard professor Charles Nelson, revealed the severely detrimental direct effects that institutional care has on the developing brains of children. A solid base of evidence and interventions, which we highlight in a new policy report on orphanhood released by the CDC, exists to prevent these outcomes: cash transfers, support for surviving parents and grandparents, and above all a commitment to avoid the mistakes of the past.

Our short-term outlook is grim. As our studies on the U.K., India and Brazil suggest, variant-driven surges look certain to wreak havoc in many countries, even already hard-hit countries, because high levels of previous infection are not fully protective. Further, evidence is emerging that moderately high levels of vaccination—as seen in the U.K.—are not protective against the Delta variant; even if the U.K. avoids another major wave of deaths, widespread infection among unvaccinated young adults could have long-lasting repercussions as a result of long COVID.

Long-term scenarios suggest millions more dead in 2021 and 2022. Whatever the true numbers, our study now reveals the hidden pandemic that accompanies them: if only another two million COVID deaths are reported in 2021, this will equate to another 600,000 children experiencing orphanhood and one million children experiencing the death of a parent, grandparent or caregiver. Epidemics grow exponentially. So too do the numbers of children directly affected. COVID can kill in a matter of days or weeks, giving families little time to prepare children for bereavement. Now is the time to rapidly respond to the hidden pandemic of orphanhood and caregiver death. Now is the time to urgently provide these children with the support they need to avoid institutionalization.