The COVID-19 pandemic has impacted the entire world, causing a global health challenge, and an escalating number of deaths. The pandemic has affected every sphere of daily life, influencing health, social life, employment and environment. While in some countries significant excess mortality has been reported, in others, excess mortality has not been demonstrated in 2020, with COVID deaths compensated for by decreased mortality in other spheres. While evidence of this secondary positive impact is encouraging, and possibly a ‘silver lining’ of the pandemic, the worrying fact is that disadvantaged groups, with lower resources at their disposal are likely to bear the brunt of the pandemic.
Sociodemographic characteristics affect the impact of COVID on individual behaviors, whether in a positive or negative direction, with the most disadvantaged members of society – with less resources and resilience - potentially suffering more, as has been demonstrated in some countries.
One notable example is the move to home working arrangements for many businesses, which has led to a significant reduction in air pollution and a reduction in the rate of car accidents, however this arrangement is only available to a proportion of workers, leaving those with more precarious menial jobs at an even greater disadvantage. Furthermore, individuals with low digital literacy are left behind in the current pandemic in terms of social support, receiving information and accessing resources which have all transferred to online versions.
Short and long-term impact
In the short term, closure of businesses and remote working from home led to a reduction in both work related accidents and traffic accidents, as well as a drop in ED visits. In addition, due to media campaigns and government policies, the importance of hygiene has been emphasized and increased, potentially reducing the spread of other viral illnesses. While reduced exposure to healthcare services may involve reduced medical errors and in-hospital infections, a decrease in community medicine referrals alongside continuing decrease in ED visits, may lead to chronic patients and high-risk populations avoiding treatment. For example, patients with ischemic stroke who hesitate before going to the ED might arrive too late for intervention that might reduce long-term complications.43
Long term social, economic and health impacts are expected to comprise the largest challenge for health care systems. The pain and suffering of the pandemic are not equally borne, with the pandemic imposing disproportionate risk and impact based on structured ethnic, class and occupational inequalities. In the words of Lisa Boleg, with 32-years’ experience with the HIV/AIDS epidemic in the United States, "We’re Not All in This Together".44
The economic and social implications of the pandemic are still only partially understood. However, it is clear that job losses are greater for ethnic minorities and less educated individuals. 45 Vulnerable populations are over-represented in occupations that require more interpersonal contact and cannot be performed remotely, and are therefore both at greater risk of exposure, and more prone to unemployment, with all its negative consequences.5,46
Despite the positive influence of decreased air pollution and hospital acquired infections, quarantine and isolation is expected to increase the rate and severity of mental illness and suicides. This is also likely to disproportionately affect individuals with low resources and resilience. For example in the South Korean economic crisis of 1997, suicides were more prevalent in those with lower educational level.47
Additionally, avoiding medical treatment due to fear of infection or overload on the healthcare system, may delay timely diagnosis of diverse risk factors and health conditions, including for example abnormal lipid profile, hypertension and pre-diabetes. In the long-run this will cause an increase in the prevalence of diabetes and cardiovascular diseases leading to increased mortality rates for acute conditions such as myocardial infarction and stroke.
The proposed theoretical model might help policy makers, healthcare professionals and researchers to have a better and more holistic perception of the consequences of the pandemic. Implicitly, the mission is to create a better balance between the opposing forces of the scale, with reduced overall mortality. Indeed, not all the components on both sides of the scales are amenable to intervention within the health system; some - like the economic burden that contributes to ill health – are beyond its scope of influence, yet should be taken into consideration by government decision-makers. Yet, much can be done while the pandemic is ongoing, as well as after it abates. Special attention should be paid to the vulnerable segments of the population, where most preventive measures should be directed to reduce the health consequences of this crisis.
While developed in relation to the COVID-19 pandemic, the model is also relevant to the impact of other major events, including war, natural disaster and economic depression. The external pressures may vary, but the mechanism and essential effect of internal resources remain the same.
With both positive and negative impact on mortality, it remains unclear which way the scales will tip. However, as the long-term effects of the pandemic are likely to stay for some years, decision makers should consider diverting the resources gained from decreased mortality to better support vulnerable populations during the pandemic and as part of the exit strategy.
By shedding light on the underlying mechanisms and human behaviors that influence the outcomes of a health disaster, the model developed here can improve preparedness of the healthcare system and society at large by directing efforts to the most vulnerable populations. Based on the lessons learned from the theoretical model, it is recommended to define a governmental body responsible for identifying and caring for populations at risk during a health disaster. Such a body would examine how to prevent or at least reduce the widening of disparities, in order to tip the scales towards lower mortality.
In mid-December, with the start of the vaccination program, the light at the end of the tunnel is beginning to emerge. However, given limited initial supplies of the vaccine, which should eventually dramatically decrease viral spread, it might still take many months before a considerable part of the world will be vaccinated. Being able now to look beyond the pandemic, it is important to delineate which factors move the arms of the scales in the "right" direction and try to preserve these processes when life returns to some kind of normal.