The health burden of the current pandemic will extend far beyond the direct impact of Covid-19 morbidity and mortality. We must use evidence to mitigate the wider, indirect effects to protect and improve the long-term health of our population.
The UK has recently recorded increases in confirmed cases, hospital admissions and deaths from Covid-19. A second wave of the pandemic, with severe health consequences, is underway.
Leadership is needed to reduce both direct and indirect harms to population health. Unfortunately, political and scientific debates have been unhelpfully framed as a trade-off between controlling the pandemic and minimising the wider consequences of our policy response. In fact, we need both a strong direct response to the pandemic and strong measures to mitigate its indirect impacts. However, the role of evidence-based public health leadership has been much clearer in the former than in the latter.
This lack of clarity matters because the indirect health effects of Covid-19 are substantial. Frameworks published in April and June anticipated and outlined an array of short, medium, and long-term health and equity effects arising from the pandemic and resulting control measures. There is now a growing evidence base modelling the scale of these impacts or demonstrating them in practice. Some effects have been felt already, and some will be seen in the long term. They include:
- Displaced healthcare services, and decreased use of remaining services, for example leading to excess mortality from cancer or cardiovascular disease in addition to wellbeing impacts from losses to community services.
- Mental health effects - including in children - arising from social isolation, uncertainty, economic insecurity, bereavement, anxiety about exposure to the virus and working conditions
- Changing or inequitable access to green space, physical activity and healthy food; and new patterns of alcohol use, smoking and gambling.
- Changes in exposure to environmental health hazards including overcrowded or poor-quality housing, or temporary accommodation.
- Economic and employment impacts, which are inextricably linked with health outcomes.
- long-term effects on the life chances and health of a generation of children and young people arising from educational disruption, loss of social contact, missed safeguarding opportunities, and exclusion from the workforce.
Just as there is evidence that the direct effects of Covid-19 are disproportionately felt by some social groups, there is also evidence that the indirect effects harm some more than others, often reflecting existing inequalities. The initial weeks of lockdown in the UK saw a clear socioeconomic gradient in adversities related to basic needs such as access to food and medication. Consequences for Black, Asian and Minority Ethnic communities have also been profound. Impacts on other groups may be specific to the current crisis: for example, young workers, women, and low earners are more likely to have been employed in sectors that were shut down as part of the government’s response.
Importantly, there are national and local examples of measures to mitigate potential risks to both short and long-term population health. National and regional initiatives include tenancy protection for renters, emergency accommodation for rough sleepers and job protection schemes.
A second wave brings an urgent need to draw on this evidence and good practice about the indirect population health impacts of Covid-19 and how to mitigate them. As policies and support schemes change, focus is needed on populations that may become newly vulnerable. But at the time this analysis is most needed, the capacity to carry it out is insufficient at both national and local level.
Technical advice to UK governments comes from the Scientific Advisory Group for Emergencies (SAGE). SAGE has multiple subgroups ranging from epidemiological modelling, to behavioural responses, to infection control. It does not have a subgroup on wider public health consequences.
Public Health England should be the organisation best placed to consider wider population health in England. It has produced useful resources to understand and mitigate the pandemic’s impacts. However, it is being disbanded and the future of its health improvement functions remains undecided.
At local level, Directors of Public Health have an important leadership role. Unfortunately, their teams have seen their long-term resilience eroded by funding cuts, and many frontline staff have been diverted to support the direct pandemic response. Other public services including healthcare, social care, education and housing have an important role here, and are also stretched.
National, regional and local public health capacity is needed now to help translate evidence of the wider pandemic impacts into concrete action across different sectors. If we fail to learn from the first wave, we risk exacerbating the impacts of the pandemic and doing unnecessary harm to mental and physical health for years to come.
This article is based on the findings from a series of rapid evidence reviews and consultation conversations with key London stakeholders, exploring the wider impacts of the pandemic and the considerations for recovery, within the context of improving population outcomes. The full report is available here.
