The COVID-19 pandemic represents an unprecedented challenge. Policy makers, the medical
and research community, as well as the wider public have rightly focussed on the deaths
caused by the virus. However, we believe there are three further ways in which this
pandemic will affect mortality rates around the world.
First, there is the likely mortality rise during the pandemic as health system resources
are diverted to helping COVID-19 patients. Interruptions to planned care (e.g. for
cancer) and even to non-elective care are likely to cause a modest but significant
spike in non-COVID-19-related deaths. For example, one study showed that most head
and neck cancers double in size within 1–3 months (Jensen et al. 2007). Delays to
screening or management are likely to generate a much higher caseload of late-stage
Second, there is the effect of the ensuing recession, characterised by potentially
record levels of unemployment in many countries. In general, health outcomes improve
during recessions, mostly driven by fewer cardiovascular-related deaths possibly as
a result of more active lifestyles (Strumpf et al. 2017). On the other hand, some
disease outcomes worsen, such as suicides (Reeves et al. 2012) and treatable cancers
in countries without universal health coverage (Maruthappu et al. 2016). In this recession
though, the pandemic-enforced home isolation could mean that the aforementioned cardiovascular
benefits do not materialise, leading to a net rise in mortality rates.
Finally, there is the consequence of the economic response. If countries respond with
austerity measures that lead to a real-terms decline in public health and social care
spending, we could see hundreds of thousands of ‘excess’ deaths or more. Our work
and that of others have shown that reducing spending without gains in health system
efficiency is associated with poor outcomes across all disease areas (Watkins et al.
To mitigate the negative effects of the first and second points, governments should
start defining strategies on when and how to safely exit from lockdown measures as
soon as possible. Health system capacity along with the number of new cases and hospitalisations
over time, and the emergence of new pharmaceutical interventions are critical inputs
to an exit strategy. There are at least three benefits to making plans for an exit
strategy now. First, it returns focus on the system capacity measures and pharmaceutical
interventions that can save lives independent of non-pharmaceutical demand management
measures. Second, it gives visibility to government departments and other organisations
on what needs to be put into place for a successful recovery once measures are lifted.
Finally, it generates public confidence in policy makers possibly improving adherence
to ongoing demand management measures.
To address the economic response challenge, governments need to be prepared to maintain
health and care spending in line with demand. Avoiding austerity through increased
borrowing or reallocating of budgets is merely a couple of the mechanisms by which
such spending objectives could be achieved.
In summary, therefore, the number of lives lost due to COVID-19 has the potential
to be dwarfed by the number of lives lost as a result of these three knock-on effects
of the pandemic. Governments can prevent or mitigate this effect by: (1) planning
and communicating an exit strategy early to avoid needlessly protracted lockdowns
and/or ill-prepared exits and (2) seeking to maintain public health and social care