The health effects of the pandemic could be with us for decades to come. But with concerted efforts and investment, we can limit these harms while creating a society that is more effective in preventing and withstanding future blows to public health.
There must be few people who remain untouched by the health effects of the pandemic since it first upended our lives two years ago. Whether you or your loved ones have been hit by Covid-19 infections, felt your mental health suffer or had your non-Covid-19 medical concerns caught up in the NHS backlog, the effects of the virus have infiltrated all areas of health and healthcare.
The health effects of the pandemic are clearly wide-ranging, but they can be categorised into three ‘orders’ (Fisayo and Tsukagoshi, 2021):
- First-order effects. These are the direct effects of the virus: infections, deaths and the condition known as long Covid.
- Second-order effects. These are indirect effects, largely in the short to medium term, stemming from measures implemented to control the pandemic. They include unmet health needs arising from the NHS backlog, and the mental health effects of lockdowns.
- Third-order effects. These are longer-term, indirect effects caused by the impact of the virus on key social influences on our health, particularly employment and education.
This article provides an overview of these effects. It offers insights from public health research that is relevant to decisions on how to allocate resources as, two years into the pandemic, we continue to live with Covid-19 and must find more ways to limit its damage.
While Covid-19 may have affected us all to one degree or another, its impacts have not fallen equally across society. The pandemic has increased health inequalities, creating a wider gap that may take decades to close. These social disparities are highlighted to show how resources could be targeted, but also how moves to reduce inequalities and improve social cohesion will create a more resilient society – and one that is better equipped to cope with health risks of all kinds.
What have been the direct health effects of the pandemic?
On 29 January 2020, the UK confirmed its first positive tests for Covid-19. The patients were a student and his mother who had recently arrived from Wuhan, where the world’s first case of Covid-19 had been confirmed a month earlier.
From January 2020 to late March 2022, there have been 20.6 million confirmed cases of Covid-19 in the UK. In the same period, there have been over 774,000 hospitalisations and 164,000 deaths (within 28 days of a positive Covid-19 test).
Successive waves of infection – driven by new mutations and changes in public behaviour – have been tempered by containment and suppression. This has led to the formation of the now familiar ‘mountain ranges’ of infection, hospitalisation and death rate charts.
Critically, and most notably in the most recent Omicron-dominated wave, we no longer see hospitalisations and deaths reaching the same heights as infection cases (see Figure 1). This is largely thanks to the biggest vaccination programme in the UK’s history.
Figure 1: Covid-19 cases, hospitalisations and deaths
Panel A: Infections – percentage testing positive for Covid-19
Panel B: Hospital admissions – weekly admission rate per 100,000
Panel C: Deaths involving Covid-19 – weekly deaths registered
Note: Data for England only. The first pink line corresponds to the emergence of the Alpha variant, the second pink line corresponds to the emergence of the Delta variant, and the third pink line corresponds to the emergence of the Omicron variant.
At the end of January 2022, around 2.4% of the UK population (1.5 million people) were living with self-reported symptoms of long Covid (ONS, 2022). Four in ten (45%) of these people had been experiencing symptoms for at least a year after the first (suspected) infection. Around two-thirds (65%) said that their condition adversely affected their day-to-day activities.
There is still much to learn about long Covid. A better understanding of its vast range of symptoms – over 100 have been identified so far (Hayes et al, 2021) – will help healthcare planners to allocate resources between disciplines, whether neurology or respiratory health, for example. It will also inform how they can work together effectively.
Recent findings show that double-vaccinated Covid-19 patients are 50% less likely to develop symptoms of long Covid, compared with the unvaccinated (Antonelli et al, 2022). This is encouraging, and adds to the impetus to get people vaccinated.
What are the social disparities in Covid-19 infections and deaths?
Vaccines are not the only things to offer protective effects against Covid-19. Relative privilege has also limited a person’s chances of infection. It affords greater opportunity to practice social distancing – through working from home, for example – and a lower likelihood of existing health vulnerabilities. As one study notes, ‘socio-economic status (SES) is a matter of life and death when it comes to the way people are affected by the virus’ (Khedmati Morasae et al, 2022).
Some socio-economic groups are at greater risk of catching Covid-19, and of suffering worse effects. The differences reflect patterns of structural inequality that were already present before the pandemic and well understood by both social and health scientists.
To give some statistical examples, UK data show that areas of the country with low deprivation and low ethnic minority populations experienced average Covid-19 rates of 0.369% between June 2020 and Sept 2021, compared with 0.405% in areas with high deprivation and high ethnic minority populations (Padellini et al, 2022). Research also shows that the risk of death involving Covid-19 in the UK was 3.7 times greater for people with a learning disability compared with people of the same age without one (Flynn et al, 2021).
A study of patients with Covid-19 admitted to critical care units in Scotland during the first wave of the pandemic revealed that 24.9% were from the most deprived fifth of the population and 13.6% from the least deprived. Death was 1.97 times more likely for patients from the most deprived fifth (Lone et al, 2021).
Some health inequalities have shifted over the pandemic. The first wave hit ethnic minority populations harder than white British populations. But studies show that by the second wave, risks had dropped for all ethnic minority groups except South Asian communities, even matching those for white British populations (Nafilyan et al, 2021; Mathur et al, 2021; Padellini et al, 2022).
It has been suggested that this may be thanks to the effects of public health messaging in changing behaviour across most of the UK population. But this messaging may not have been well targeted to South Asian groups (Nafilyan et al, 2021).
It was also insufficient to overcome deeper structural issues, such as the higher numbers of South Asian people in public-facing or key worker roles. Among the UK’s South Asian population, 7% are defined as critical workers by the ONS – compared with, for example, 3.3% of the black population (Padellini et al, 2022).
What are the indirect health effects of the pandemic in the short and medium term?
The shift in NHS activity to prioritise Covid-19 patients, as well as government stay-at-home orders and school closures, have been key components of the national pandemic strategy. But these have all added to widening health inequalities. Crucially, they will lead to increases in ill-health and death rates in coming years, for which healthcare providers must prepare.
Two years of the pandemic have taken a large psychological toll. Research shows that the number of people with anxiety almost doubled during the first wave, rising from 13% to 24% (Kwong et al, 2021).
Continued monitoring of mental health will be important to help to shape public health responses. For example, data collected by the Covid-19 Social Study reveal a sharp increase in depression and anxiety symptoms over the Christmas 2021 period in the UK, coinciding with the rise of the Omicron variant. This was especially evident among younger people (Fancourt et al, 2022).
Indeed, among all social groups, research consistently identifies young people as having taken one of the biggest hits to mental health. The same is true for other groups whose lives have been most disrupted by the pandemic, including through greater financial uncertainty, job loss or increased childcare responsibilities during school closures. These are all factors that can reinforce one another.
The groups include low-income families, ethnic minority groups, women and parents with young children (Aknin et al, 2022; Banks and Xu, 2020; Kwong et al, 2021; Serrano-Alarcón et al, 2022). The UK Household Longitudinal Study shows that in the early stages of the pandemic, men suffered a 7.5% increase in mental distress compared with the year before. For women, the increase was 13.5%. Bangladeshi, Indian and Pakistani respondents experienced an increase of 18.22% in mental distress.
Warnings have been issued about the longer-term impacts of mental distress during the pandemic on the highly concerning issue of suicide (Paul and Fancourt, 2022). While suicides did not increase over the first year of the pandemic, known risk factors for suicide did. These include unemployment, mental health problems, domestic violence and insufficient access to mental healthcare, which were accompanied by increases in self-harm thoughts and behaviours. Evidence from past crises, such as natural disasters and recessions, indicates that higher suicide rates tend to come after the event.
Policies to improve economic wellbeing can make a difference here. For example, following the global financial crisis of 2007-09, an increase of 1% per capita in government spending to mitigate the effect of financial hardship was associated with a 0.2% decrease in suicides in Japan (Matsubayashi et al, 2020).
The pandemic and school closures have also affected the health of children and adolescents. A UK survey during lockdown found that 53% of girls and 44% of boys aged 13-18 had symptoms of anxiety and trauma (Levita et al, 2021).
Another study estimates that missing a whole six weeks of school could increase behavioural and emotional difficulties by more than one standard deviation – roughly equivalent to children newly exhibiting three or four serious negative behaviours or emotional difficulties (Blanden et al, 2021). The researchers warn that going back to school in itself is not sufficient for children to ‘bounce back’, and that additional support for children’s mental health and wellbeing will probably be needed for some time.
School closures and other aspects of the pandemic have also affected health behaviours, bringing concerns that worsening diet and exercise habits throughout the pandemic may also increase future demand for healthcare.
But studies reveal a varied picture of health behaviours across the population. The shock of the pandemic has led many people to make healthier choices, for example, exercising more or eating more fruit and vegetables. In a 2020 study of over one million people in the UK and United States, the ZOE COVID project found that around a third of participants gained weight, while another third lost weight, with weight increases more likely among poorer participants (Mazidi et al, 2021).
Schools are an important source of exercise and nutritious food for many children. A study of the health effects of school closures on young children in Wales shows detrimental outcomes for poorer children, who ate fewer fruits and vegetables than before the pandemic. They also exercised less and ate more takeaways than children from wealthier households (James et al, 2021). Excess weight gained by children during this pandemic could be difficult to reverse and persist into adulthood, placing an additional future burden on the healthcare system.
Unmet health needs
Recent data for England show consistent failure to meet NHS targets, including waiting times for treatment, screenings (such as MRI scans) and ambulances (Baker, 2022). This was true before 2020, and while waiting lists have been growing since 2012, they have grown longer during the pandemic.
In July 2021, nearly 6.1 million patients were on the waiting list for consultant-led treatment in England – the highest waiting list in the current time series going back to 2007. In April 2020, treatments involving admission to hospital were 85% lower than the previous year. Activity has since recovered but remains below pre-Covid-19 levels. In December 2021, there were 14% fewer admitted treatments (-1,148 per day) than there had been in December 2019.
Figure 2: Waiting list for hospital treatment
We have also seen a big drop in patients making appointments, perhaps partly due to fear of infection or to avoid putting an extra burden on health services.
A large study found a reduction in primary care appointments for a vast range of health conditions in the months following the onset of Covid-19 restrictions in the UK. The largest reductions were in appointments for diabetic emergencies, depression and self-harm (Mansfield et al, 2021). These findings emphasise the importance of maintaining healthcare access in future public health planning, including potential further restrictions.
School closures also saw fewer opportunities for schools to report suspected cases of child abuse, with child protection medical referrals dropping by 35-50% in the UK (Viner et al, 2022).
Women, black ethnic groups and poorer groups have been most likely to have prescriptions or medication access, procedures, surgery and clinical appointments disrupted (Maddock et al, 2021). This trend could result in existing health inequalities being exacerbated.
Separate analysis finds that in July 2021, 7% of patients on waiting lists for planned hospital treatment in the most deprived areas of the country had been waiting at least a year, compared with 4% in the least deprived areas (Mahase, 2021).
What are the indirect, long-term health effects of the pandemic?
The health effects of the pandemic could be felt for many decades through its influence on the social determinants of health and on the next generation (Fisayo and Tsukagoshi, 2021).
The health impacts of economic downturns are complex, but they typically serve to worsen health inequalities. It is likely that groups that suffer both poverty and poor health will be most affected in the longer term (Banks et al, 2020).
Fortunately, unemployment levels have not been as high as was first feared. But younger people have been affected particularly severely, given the pandemic’s effects on sectors in which large numbers of them work (such as in shops or bars/restaurants).
This is a concern given that youth unemployment can have lasting consequences for anxiety, depression and suicidal thoughts, which persist into middle age (Virtanen et al, 2016). Around two-thirds of 18-24 year olds who have lost work during the pandemic have reported mental health issues (Resolution Foundation, 2022).
Other groups of particular concern include families with young children or where mothers are pregnant. Economic shocks and downturns during pregnancy and early childhood can have lifelong physical health and cognitive effects (Banks et al, 2020).
There are further reasons to be concerned about the health effects of school closures. Education is one of the strongest determinants of health (World Health Organization, 2008), with clear evidence that learning losses lead to long-term reductions in health and life expectancy (Conti et al, 2010). Despite teachers’ best efforts, there will be children who never make up for their months of missed education and could experience worse health over their lifetimes as a result of lower earnings (Fisayo and Tsukagoshi, 2021).
Looking to the future: what are the big healthcare lessons from the pandemic?
In wealthy countries, at least, we can begin to talk about the move from pandemic to endemic (The Lancet Respiratory Medicine, 2022). Yet at the time of writing, cases are rising sharply again, we remain at risk of more serious mutations, and it is unlikely this will be the last pandemic. Research provides several lessons to help policy-makers prepare for and navigate these coming challenges.
Targeting disadvantaged groups
Effective and timely public health and healthcare measures that target the communities at greatest risk are urgently needed to avoid further widening of inequalities (Davies et al, 2021). For example, given the higher concentrations and more lethal effects of Covid-19 infections in more socio-economically deprived areas, additional resources could be deployed to critical care units (Lone et al, 2021)
More resilient healthcare providers
The pandemic has raised big questions about how prepared the NHS was for coronavirus, as well as whether it is sensible for the NHS to be operating at close to full capacity during non-pandemic times. Overall, the evidence demonstrates that in the last decade, the NHS has not been provided with enough public funding to enable it to grow and meet increasing demand for healthcare services. There are widespread calls for more investment to deal with the NHS backlog, including more staff recruitment.
A more resilient society
Strong and resilient health systems are clearly important, but up to 90% of our health is determined outside the health system (McGovern, 2014). A better appreciation of social care, schools, workplaces and local authorities as managers and preventers of ill-health and inequality will also be important.
Furthermore, we will have better public health if these services are better coordinated with one another. For example, the limited role of the state in funding, delivering and regulating social care has contributed to many of the serious challenges faced by this sector during the pandemic, such as the 30,000 more deaths among care home residents than expected in the first half of 2020.
A more resilient economy
To address the health inequalities brought to the fore by Covid-19, we should ‘not pretend we can plaster over them with individually targeted healthcare interventions after the damage has already been done’, as one health researcher writes (Stokes, 2022). Looking to economic interventions will also help to address these inequalities. For example, strategies to reduce unemployment improve health. Even a 1% fall in employment leads to a 2% increase in the prevalence of chronic illness, research from the Institute for Fiscal Studies (IFS) shows (Janke et al, 2020).
Countries that have performed badly during the pandemic, in terms of infection and death rates, are often those where the government has been initially dismissive or sceptical of new scientific evidence (including the UK). This has contributed to lower public trust in the government response (Haldane et al, 2021).
A study of 177 countries estimates that if all of them could achieve the same level of trust in government as in Denmark (in the 75th percentile for trust), global Covid-19 infections could have been reduced by 12.9% (Bollyky et al, 2022). If they had all had the same level of interpersonal trust (trust in other people generally) as in Denmark, global infections could be 40.3% lower. And if any further reason was needed to reduce social disparities, low interpersonal trust is highly correlated with income inequality.
The past two years have shown how the health effects of pandemics extend far beyond infections. They have also exposed weaknesses in healthcare and social infrastructure. But importantly, they have also yielded a rich set of lessons that could help to shape a healthier future for all, both during the remainder of the Covid-19 pandemic and beyond.
Where can I find out more?
- ZOE Covid Study: The world's largest study of Covid-19, and nutrition.
- The NHS backlog recovery plan and the outlook for waiting lists: IFS report, February 2022.
- Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: A national observational study.
- Mental health and Covid-19: World Health Organization.
- Double trouble – Exploring the labour market and mental health impact of Covid-19 on young people: Report from the Resolution Foundation.
Who are experts on this question?
- Carol Propper
- Rachel Griffith
- Flavio Toxvaerd