compare and contrast life before and after covid 19 essay

Human Life Before and After COVID-19 Pandemics Research Paper

Introduction, human life: before and during covid-19, post covid-19, works cited.

The ongoing coronavirus disease of 2019 (COVID-19) can be studied as one of the most dangerous diseases in the recent times. This condition has led to unprecedented problems that have shaken all aspects of human life. Before the onset of this disease, many economies were performing optimally and capable of meeting the demands of the targeted citizens. Unfortunately, the condition forced governments to implement lockdown measures to reduce its spread. The imposed initiatives have affected human life and the global economy negatively by creating money problems, triggering unprecedented job cuts, and compelling companies to downsize.

COVID-19 is a pulmonary infection that has claimed thousands of life in different parts of the world. Experts have agreed that the disease was reported for the first time towards the end of 2019 in Wuhan, China. The forces of globalization and international transport are believed to have led to the spread of COVID-19 across the globe. By March 2020, this condition had already been recorded in most of the countries in different continents (Sikder et al. 328). The mysterious nature and complexity of COVID-19 forced governments to institute a wide range of measures that would minimize human contact and travel.

Some of the implemented strategies included washing hands with soaps, carrying and using hand sanitizers, and keeping social distance. Communities and regions would rely on the power of lockdown measures to achieve better results within a short period. Nonetheless, many people continued to contract the virus with some of them losing their lives (Lebleu). Within the last twelve months, international health organizations, pharmaceutical companies, and world health organization (WHO) have been working hard to get an effective vaccine and support the anticipated economic recovery.

Economic growth depends on the inputs the government provides and the measures different people put in place. Before COVID-19, many countries were performing optimally and engaging in international trade (“Coronavirus World Map”). Most of the people were able to get better jobs and earn competitive salaries. Most of the companies and industries were able to achieve their goals due to the processes of globalization. International trade was also undisturbed for many decades. Such forces were making it possible for some of the emerging economies to compete with giant ones (Sikder et al. 329). For example, China and Brazil were capable of producing additional goods and meeting the increasing demand in the global market.

These scenarios reveal that many people were leading better lives in most of the successful countries. For instance, unemployment rates had reduced significantly in both the developing and the developed world. The changing social and cultural dynamics were allowing people to travel across the globe and search for new job opportunities. Such trends were capable of transforming the experiences and lives of many citizens (Lebleu). Most of the implemented fiscal policies and economic stimulus packages had the potential to improve performance.

Unfortunately, the emergence of this pulmonary disease led to sweeping social, economic, and cultural changes across the globe. First, the imposed transportation measures and curfews worsened the situation for many people. Those who had travelled to other countries were unable to go back to their regions (Lebleu). Some were compelled to stay at home for over two months. Such developments affected the gains that had been recorded within the past two decades. Second, the lockdown measures meant that most of the people were unable to work or open their businesses. Such individuals could not earn any form of income, thereby being forced to exhaust their savings.

Third, most of governments were keen to introduce additional measures that could reduce the spread of COVID-19. For instance, individuals who were found to have the disease after testing were quarantined or hospitalized. The idea of contact tracing was also considered to identify people who could be having the condition. Consequently, millions of people across the globe were forced to isolate or engage in self-quarantine (see Fig. 1). Those who had travelled to countries with reported cases had to quarantine themselves. Such measures were capable of supporting the fight against the COVID-19 (Petersen et al. 234). However, the consequences were felt across the globe since many people lost their jobs or were unable to earn a living.

Fourth, the instituted measures proved to be more catastrophic and damaging to small businesses enterprises. Over the decades, such investments had been promoted due to their capabilities in addressing poverty and empowering more people to transform their lives. The lockdown measures compelled most of these entities to close for good. This trend meant that their owners would be unable to earn a living or pursue their social and economic goals (Kebede et al. e0233744). Those who lacked adequate savings were affected the most by these measures. Similarly, companies operating in different sectors had to downsize and reduce the number of workers to minimize infections.

While the outlined measures were critical to deal with this disease, many experts acknowledged that they were harmful to the lives and experiences of many individuals. Such initiatives led to numerous challenges associated with job losses and poor economic performance. The decision to close schools and other social functions indefinitely affected many people negatively (Petersen et al. 234). Some of the individuals who contracted the virus were forced to use their savings for medication purposes. These issues explain why life has changed significantly in different parts of the world. Without proper mechanisms and strategies to mitigate the disease, chances are high that more individuals will continue to experience similar challenges and be unable to achieve their maximum potential.

Currently, the impacts of COVID-19 are being experienced in both the developed and developing countries. However, Europe and America were some of the continents that suffered due to this disease. Some experts indicated that certain parameters were capable of describing such trends, including population size, age, and travel history (*). Fortunately, most of the nations in the African and Asian continents were not affected the most by this condition. Nonetheless, the implemented strategies were observed to trigger numerous challenges that would change the world forever.

Post COVID-19 is a hypothetical period or era that is expected after human beings succeeded in treating and getting rid of this disease. In such a scenario, scholars believe that most of the countries will continue to feel the impacts of this condition in different ways (Petersen et al. 236). For instance, those who lost their jobs in the developing world might be hit the hardest since businesses and industries might take long to recover. The predicted reliance on modern technologies means that individuals born from the 1980s would be able to use such innovations to complete their jobs (“Coronavirus World Map”). Older people will encounter additional challenges since they have been relying on traditional methods of production.

Governments in the underdeveloped world will be unable to provide adequate stimulus packages and financial resources to support emerging businesses. Such regions lack proper mechanisms and contingency plans to deal with the shocks of this pandemic. This reality means that most of the affected firms will be unable to hire more people and provide high-quality support to the targeted clients (“Coronavirus World Map”). The race to get a vaccine is an initiative that is expected to consume financial resources. More countries will also be compelled to incur huge expenses to acquire immunizations for their citizens. These priority areas would indicate that the recovery process might take longer that many people would expect.

Those who have lost their loved ones and jobs will find it hard to restore their life experiences. Governments might be unable to implement proper mechanisms and initiatives that can help more people to transform their situations (Petersen et al. 235). This knowledge should encourage policymakers and experts to consider some of the best ways to address the predicted challenges. Companies, institutions, and government agencies should also transform their models in such a way that they help mitigate the predicted predicaments in the anticipated post-COVID-19 world.

The ongoing COVID-19 has led to numerous challenges that have transformed human life in different ways. Most of the affected people have lost their jobs, thereby being unable to provide for their children and relatives. The instituted measures have worsened the condition for small-small businesses and workers. The move to find a vaccine for this disease means that governments will exhaust most of their resources, thereby making the process of recovery unpredictable. The developing world is expected to encounter numerous challenges due to the absence of proper contingency plans to deal with pandemics.

“ Art and Lockdown: Your Drawings in the Time of Coronavirus .” Voices of Youth, 2020, Web.

“ Coronavirus World Map: Tracking the Global Outbreak .” The New York Times, 2020, Web.

Kebede, Yohannes, et al. “Knowledge, Perceptions and Preventive Practices towards COVID-19 Early in the Outbreak among Jimma University Medical Center Visitors, Southwest Ethiopia. PLoS ONE , vol. 15, no. 5, 2020, p. e0233744.

Lebleu, Rita. “ After Surviving 2 Hurricanes, COVID-19, A Family is Blessed .” The Washington Times, 2020, Web.

Petersen, Eskild, et al. “COVID-19-We Urgently Need to Start Developing an Exit Strategy.” International Journal of Infectious Diseases, vol. 96, no. 1, 2020, pp. 233-239.

Sikder, Mukut, et al. “The Consequential Impact of the Covid-19 Pandemic on Global Emerging Economy.” American Journal of Economics, vol. 10, no. 6, 2020, pp. 325-331.

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IvyPanda. (2022, February 28). Human Life Before and After COVID-19 Pandemics. https://ivypanda.com/essays/human-life-before-and-after-covid-19-pandemics/

"Human Life Before and After COVID-19 Pandemics." IvyPanda , 28 Feb. 2022, ivypanda.com/essays/human-life-before-and-after-covid-19-pandemics/.

IvyPanda . (2022) 'Human Life Before and After COVID-19 Pandemics'. 28 February.

IvyPanda . 2022. "Human Life Before and After COVID-19 Pandemics." February 28, 2022. https://ivypanda.com/essays/human-life-before-and-after-covid-19-pandemics/.

1. IvyPanda . "Human Life Before and After COVID-19 Pandemics." February 28, 2022. https://ivypanda.com/essays/human-life-before-and-after-covid-19-pandemics/.

Bibliography

IvyPanda . "Human Life Before and After COVID-19 Pandemics." February 28, 2022. https://ivypanda.com/essays/human-life-before-and-after-covid-19-pandemics/.

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COVID-19: Where we’ve been, where we are, and where we’re going

One of the hardest things to deal with in this type of crisis is being able to go the distance. Moderna CEO Stéphane Bancel

Where we're going

Living with covid-19, people & organizations, sustainable, inclusive growth, related collection.

The Next Normal: Emerging stronger from the coronavirus pandemic

Life before and after COVID-19: The 'New Normal' Benefits the Regularity of Daily Sleep and Eating Routines among College Students

Affiliations.

• 1 Department of Nutrition, Food Science, and Gastronomy, Food Science Torribera Campus, University of Barcelona, 08921 Barcelona, Spain.
• 2 Nutrition and Food Safety Research Institute, INSA-UB, 08921 Barcelona, Spain.
• PMID: 35057529
• PMCID: PMC8777903
• DOI: 10.3390/nu14020351

After the COVID-19 lockdown, a 'new normal' was established, involving a hybrid lifestyle that combined face-to-face with virtual activity. We investigated, in a case-control study, the impact of the 'new normal' on daily sleep and eating routines, compared with pre-pandemic conditions. To do this, we propose using social and eating jet lag as markers of the regularity in daily routines. Additionally, we studied whether the 'new normal' had an impact on the body mass index (BMI), diet quality, and other health-related variables. This study included 71 subjects in the pre-pandemic group, and 68 in the 'new normal' group (20-30 years). For all participants, we evaluated social and eating jet lag, BMI, diet and sleep quality, eating behaviors, physical activity, and well-being. General linear models were used to compare outcome variables between pre-pandemic and 'new normal' groups. The results revealed that the 'new normal' was associated with greater regularity in daily sleep and eating routines (-0.7 h of social jet lag (95% CI: -1.0, -0.4), and -0.3 h of eating jet lag (95% CI: -0.5, -0.1)), longer sleep duration on weekdays (1.8 h (95% CI: 1.5, 2.2)), and lower sleep debt (-1.3 h (95% CI: -1.7, -0.9)). Regarding BMI and other health-related variables, we observed that these variables were similar between 'new normal' and pre-pandemic groups. These findings indicate that the 'new normal' had a positive impact on daily sleep and eating routines. Additionally, our results indicated that the 'new normal' offered college students a more sustainable lifestyle, which was associated with more hours of sleep during the week and lower sleep debt. This, in the long run, could have a positive impact on BMI and overall health.

Keywords: COVID-19; daily routines; eating jet lag; meal timing; sleep; social jet lag.

• Body Mass Index
• COVID-19 / prevention & control*
• Case-Control Studies
• Diet / statistics & numerical data*
• Exercise / statistics & numerical data
• Feeding Behavior*
• Linear Models
• Sleep Quality*
• Students / statistics & numerical data*
• Universities
• Young Adult

Grants and funding

• DOCTORADO BECAS CHILE/2019 - 72200134/Agencia Nacional de Investigación y Desarrollo

• PERSPECTIVES
• SUBMIT A PERSPECTIVE
• A NEW MAP OF LIFE

THE NEW MAP OF LIFE

AFTER THE PANDEMIC

It is said that culture is like the air we breathe. We don’t notice it until it’s gone.

The COVID-19 pandemic is bringing into focus a once invisible culture that guides us through life. Seemingly overnight, we experienced profound changes in the ways that we work, socialize, learn, and engage with our neighborhoods and larger communities.

For a short time, before new routines and practices replace familiar old ones, we can see with greater clarity the positive and negative aspects of our former lives. The suddenness and starkness of this transformation allows us to examine daily practices, social norms and institutions from perspectives rarely allowed.

The fragility of the global economy becomes glaringly apparent as critical supply chains faulter, unemployment surges, and markets vacillate. Tacit assumptions about health care systems become clear as we see how they function, fail to function, and have long underserved large parts of the population. Just as sure, sheltering in place allows us to appreciate precious details of our lives that we have taken for granted: the appeal of workplaces, the comfort of human touch, dinner parties, travel, and paychecks. Indeed, through ambivalent eyes we also recognize ways that life is better as we shelter in place.

The premise of the New Map of Life:™ After the Pandemic project is that we have a fleeting window of time that affords us an unprecedented opportunity to examine our lives.  Going forward, life will be different and by compiling the insights we have today we can inform and guide the culture that will inevitably emerge from our collective experience. Your insights can contribute to the reshaping of social norms, systems, and practices that shape our collective futures.

Since the founding of the Stanford Center on Longevity, we have advocated for a major redesign of life that better supports century-long lives. More recently, we undertook the New Map of Life ™ initiative, which focuses on envisioning a world where people experience a sense of purpose, belonging, and worth at all stages of life. As tragedies unfold before our eyes, we aim to capture the lessons they teach. With your help, we can compile current insights, fleeting thoughts and deeper reflections about the ways we live now so that going forward we bolster, modify and reinvent cultures that improve quality of life for ourselves, our children, and future generations.

The opinions, beliefs, and viewpoints expressed by the various authors on this website do not necessarily reflect the opinions, beliefs and viewpoints of the Stanford Center on Longevity or official policies of the Stanford Center on Longevity. 

The world before this coronavirus and after cannot be the same

Professor of Globalisation and Development; Director of the Oxford Martin Programme on Technological and Economic Change, University of Oxford

Lecturer, Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio)

Disclosure statement

Ian Goldin is Professor of Globalisation and Development at Oxford University and the author of The Butterfly Defect and Age of Discovery. He has co-authored a forthcoming book Terra Incognita with Robert Muggah. It is due to be published by Penguin. @ian_goldin

Robert Muggah is the co-founder of the Igarape Institute and a principal of the SecDev Group and a regular contributor to TED and several major news outlets. His forthcoming book, Terra Incognita, co-authored with Ian Goldin, is due to be published by Penguin later in 2020.

University of Oxford provides funding as a member of The Conversation UK.

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With COVID-19 infections now evident in 176 countries , the pandemic is the most significant threat to humanity since the second world war. Then, as now, confidence in international cooperation and institutions plumbed new lows.

While the onset of the second world war took many people by surprise, the outbreak of the coronavirus in December 2019 was a crisis foretold. Infectious disease specialists have been raising the alarm about the accelerated pace of outbreaks for decades. Dengue, Ebola, SARS, H1N1, and Zika are just the tip of the iceberg. Since 1980, more than 12,000 documented outbreaks have infected and killed tens of millions of people around the world, many of them the poorest of the poor. In 2018, the World Health Organisation (WHO) detected outbreaks of six of its eight “priority diseases” for the very first time.

No one can say we weren’t warned .

Even as we attend to the countless emergencies generated by COVID-19, we need to think deeply about why the international community was so unprepared for an outbreak that was so inevitable. This is hardly the first time we’ve faced global catastrophes.

The second world war reflected the catastrophic failure of leaders to learn the lessons of the 1914-1918 war. The creation of the United Nations and Bretton Woods institutions in the late 1940s and early 1950s provided some grounds for optimism, but these were overshadowed by the Cold War. Moreover, the Reagan and Thatcher revolutions of the 1980s rolled back the capacity of governments to address inequality through taxation and redistribution and governments’ ability to deliver health and essential services.

The capacity of international institutions to regulate globalisation was undermined precisely at a time when they were most needed. The 1980s, 1990s and 2000s were a period of rapidly rising cross-border movements of trade, finance and people. The accelerated flow of goods, services and skills is one of the principal reasons for the most rapid reduction of global poverty in history. Since the late 1990s, more than 2 billion people have climbed out of extreme poverty. Improved access to employment, nutrition, sanitation and public health, including vaccine availability, added over a decade in average life expectancy to the world’s population.

But international institutions failed to manage the downside risks generated by globalisation.

Far from empowering the United Nations, the world is governed by divided nations , who prefer to go it alone, starving the institutions designed to safeguard our future of the necessary resources and authority. The WHO shareholders, not its personnel, have failed dismally to ensure it can exercise its vital mandate to protect global health.

Butterfly defect

As the world becomes more connected, it also necessarily becomes more interdependent. This is the dark underbelly, the butterfly defect of globalisation, that if left unmanaged inevitably means that we will suffer escalating, increasingly dangerous systemic risks.

One of the most graphic demonstrations was the 2008 financial crisis. The economic meltdown reflected a dangerous negligence by public authorities and experts in managing the growing complexities of the global financial system. Not surprisingly, the carelessness of the world’s political and economic elite cost them dearly at the ballot box. Campaigning on an explicitly anti-globalisation and anti-expert ticket, populists stormed to power.

Emboldened by public outrage, they have followed an ancient tradition, blaming foreigners and turning their backs on the outside world. The US president, in particular , spurned scientific thinking, spawned fake news, and shunned traditional allies and international institutions.

With evidence of infections rising fast, most national politicians now recognise the traumatic human and economic costs of COVID-19. The Centers for Disease Control’s worst-case scenario is that about 160 million to 210 million Americans will be infected by December 2020. As many as 21 million will need hospitalisation and between 200,000 and 1.7 million people could die within a year. Harvard University researchers believe that 20% to 60% of the global population could be infected , and conservatively estimate that 14 million to 42 million people might lose their lives.

The extent to which direct and excess mortality is prevented depends on how quickly societies can reduce new infections, isolate the sick and mobilise health services, and on how long relapses can be prevented and contained. Without a vaccine, COVID-19 will be a hugely disruptive force for years.

Where the damage will be worst

The pandemic will be especially damaging to poorer and more vulnerable communities within many countries, highlighting the risks associated with rising inequality .

In the US, over 60% of the adult population suffers from a chronic disease. Around one in eight Americans live below the poverty line – more than three-quarters of them live from paycheque to paycheque and over 44 million people in the US have no health coverage at all.

The challenges are even more dramatic in Latin America, Africa and South Asia, where health systems are considerably weaker and governments less able to respond. These latent risks are compounded by the failure of leaders such as Jair Bolsonaro in Brazil or Narendra Modi in India to take the issue seriously enough.

The economic fallout from COVID-19 will be dramatic everywhere. The severity of the impacts depends on how long the pandemic lasts, and the national and international response of governments. But even in the best case it will far exceed that of the 2008 economic crisis in its scale and global impact, leading to losses which could exceed $9 trillion , or well over 10% of global GDP.

In poor communities where many individuals share a single room and depend on going to work to put food on the table, the call for social isolation will be very difficult if not impossible to adhere to. Around the world, as individuals lose their incomes, we should expect rapidly rising homelessness and hunger.

In the US a record 3.3 million people have already filed for unemployment benefit, and across Europe unemployment similarly is reaching record levels. But whereas in the richer countries some safety net exists, even though it is too often in tatters, poor countries simply do not have the capacity to ensure that no-one dies of hunger.

With supply chains broken as factories close and workers are quarantined, and consumers prevented from travelling, shopping, other than for food, or engaging in social activities, there is no scope for a fiscal stimulus. Meanwhile monetary policy has been stymied as interest rates are already close to zero. Governments therefore should focus on providing all in need with a basic income , to ensure that no-one starves as a result of the crisis. While the concept of basic income guarantees seemed utopian only a month ago, it now needs to be at the centre of every government’s agenda.

A global Marshall plan

The sheer scale and ferocity of the pandemic demands bold proposals. Some European governments have announced packages of measures to keep their economies from grinding to a halt. In the UK, the government has agreed to cover 80% of wages and self-employed income, up to £2,500 ($2,915) per month , and is providing a lifeline to firms. In the US, a previously unthinkable aid package of $2 trillion has been agreed, though this is likely just the beginning. A gathering of G20 leaders also resulted in a pledge of $5 trillion , though details are slim.

The COVID-19 pandemic provides a turning point in national and global affairs. It demonstrates our interdependence and that when risks arise we turn to governments, not the private sector, to save us.

The unprecedented economic and medical response in the rich countries is simply not available to many developing countries. As a result the tragic implication is the consequences will be far more severe and long lasting in poorer countries. Progress in development and democracy in many African, Latin American and Asian societies will be reversed. Like climate and other risks, this global pandemic will dramatically worsen inequality within and between countries.

A global Marshall plan, with massive injections of funding, is urgently needed to sustain governments and societies.

The COVID-19 pandemic is not the death knell of globalisation, as some commentators have suggested. While travel and trade are frozen during the pandemic, there will be a contraction or deglobalisation. In the longer term the continued growth in incomes in Asia, which is home to two-thirds of the world’s population, is likely to mean that travel, trade and financial flows will resume their upward trajectory.

But in terms of physical flows, 2019 will likely go down in history as the time of peak supply chain fragmentation. The pandemic will accelerate the reshoring of production, reinforcing a trend of bringing production closer to markets that was already under way. The growth of robotics, artificial intelligence and 3D printing, together with customers expecting quick delivery of increasingly customised products, politicians eager to bring production home, and businesses seeking to minimise the price of machines, removes the comparative advantages of low-income countries.

It is not only manufacturing which is being automated, but also services such as call centres and administrative processes that now can be more cheaply done by computers in the basement of a headquarters than by people at distant locations. This poses profound questions about the future of work everywhere. It is a particular challenge for low income countries with a young population of work seekers. Africa alone expects 100 million workers to enter the labour market over the next 10 years. Their prospects were unclear before the pandemic struck. Now they are even more precarious.

Implications for political stability

At a time when faith in democracy is at its lowest point in decades , deteriorating economic conditions will have far-reaching implications for political and social stability. There is already a tremendous trust gap between leaders and citizens. Some political leaders are sending mixed signals and citizens are receiving conflicting messages. This reinforces their lack of trust in public authorities and “the experts”.

This lack of trust can make responding to the crisis much more difficult at the national level, and also has undermined the global response to the pandemic.

While making urgent calls for multilateral cooperation , the United Nations is still missing in action, having been sidelined by the major powers in recent years. Promising to inject billions – even trillions – into the response , the World Bank and International Monetary Fund will need to ramp up their activities to have a meaningful impact.

Owing to a shortage of international leadership from the US, cities, businesses and philanthropies are stepping up. China has gone from villain to hero in responding to the pandemic, partly by extending its soft power – in the form of doctors and equipment – to affected countries. Singaporean, South Korean, Chinese, Taiwanese, Italian, French and Spanish researchers are actively publishing and sharing their experience, including by fast-tracking research on what works.

So far, some of the most inspiring action is nongovernmental. For example, city networks such as the US Conference of Mayors and National League of Cities are rapidly sharing good practice on how to keep infectious diseases from spreading, which should improve local responses. The Bill and Melinda Gates Foundation contributed $100 million to expanding local health capacities in Africa and South Asia. Groups like Wellcome Trust , Skoll , the Open Society Foundations , the UN Foundation , and Google.org are also scaling up assistance.

Needless to say, the complexities of globalisation will not be resolved by appeals to nationalism and closed borders. The spread of COVID-19 must be met with a similarly coordinated international effort to find vaccines, mobilise medical supplies and, when the volcanic dust settles, to ensure that we never again face what could be an even deadlier disease.

Now is not the time for recriminations: it is the time for action. National and city governments , businesses, and ordinary citizens around the world must do everything they can to flatten the epidemic curve immediately, following the examples set by Singapore, South Korea, Hong Kong, Hangzhou and Taiwan.

Coalition of the willing must lead global response

Now more than ever, we need a comprehensive global response. The Group of Seven and G20 leading economies appear rudderless under their current leadership. While promising to ensure attention to the poorest countries and to refugees, their recent virtual meeting offered too little too late. But this cannot be allowed to stop others acting to mitigate the impact of COVID-19. In partnership with G20 nations, a creative coalition of willing countries should take urgent steps to restore confidence not just in the markets but in global institutions.

The European Union, China and other nations will have to step up and lead a global effort, dragging the US into a global response which includes accelerating vaccine trials and ensuring free distribution once a vaccine and antivirals are found. Governments around the world will also need to take dramatic action toward massive investments in health, sanitation and basic income.

Eventually, we will get over this crisis. But too many people will have died, the economy will be severely scarred, and the threat of pandemics will remain. The priority then must be not only recovery, but also establishing a robust multilateral mechanism for ensuring that a similar or even worse pandemic never again arises.

There is no wall high enough that will keep out the next pandemic, or indeed any of the other great threats to our future. But what these high walls will keep out is the technologies, people, finance and most of all the collective ideas and will to cooperate that we need to address pandemics, climate change, antibiotic resistance, terror and other global threats.

The world Before Coronavirus and After Coronavirus cannot be the same. We must avoid the mistakes made throughout the 20th and early 21st centuries by undertaking fundamental reforms to ensure that we never again face the threat of pandemics.

If we can work together within our countries to prioritise the needs of all our citizens, and internationally to overcome the divides that have allowed the threats of pandemics to fester, out of the terrible fire of this pandemic a new world order could be forged. By learning to cooperate we would not only have learnt to stop the next pandemic, but also to address climate change and other critical threats.

Now is the time to start building the necessary bridges at home and abroad.

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• Coronavirus
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• Published: 25 January 2022

Living conditions, lifestyle habits and health among adults before and after the COVID-19 pandemic outbreak in Sweden - results from a cross-sectional population-based study

• Anu Molarius 1 , 2 &
• Carina Persson 3  

BMC Public Health volume  22 , Article number:  171 ( 2022 ) Cite this article

3406 Accesses

11 Citations

Metrics details

Studies on the public health consequences of COVID-19 pandemic showing data based on robust methods are scarce. The aim of this study was to investigate mental and physical health as well as living conditions and lifestyle habits in the general population before and after the COVID-19 outbreak in Sweden.

The study is based on 2273 persons 16-84 years who responded to the national public health survey in February-May 2020 in Värmland county (overall response rate 45%). The differences between early respondents (before the outbreak, n  = 1711) and late respondents (after the outbreak, n  = 562) were studied using multivariate logistic regression, adjusting for background characteristics: age, gender, educational level, and country of birth. The same analyses were also completed in the corresponding survey carried out in February-June 2018.

Statistically significant differences between the groups were obtained for economic difficulties and worry about losing one’s job, which were more common among late respondents, and for sleeping difficulties, which were more common among early respondents after adjusting for background characteristics. There were no differences in other living conditions nor in lifestyle factors. Prevalence of good self-rated health, high blood pressure, aches in shoulders or neck, anxiety or worry and stress did not differ between the groups. In 2018, the only statistically significant difference between early and late respondents concerned economic difficulties.

Conclusions

Very few differences in living conditions, lifestyle factors and health were observed in the study population before and after the COVID-19 outbreak. The results suggest that, in addition to a possible decrease in sleeping difficulties, the prevalence of being worried about losing one’s job increased among the employed after the outbreak.

Peer Review reports

In March 2020, the worldwide pandemic of coronavirus causing COVID-19 reached Sweden. This led to restrictions in many sectors of society, an increased burden on health care, and an economic downturn with a sharp increase in layoffs and unemployment. The impact of the pandemic on the mental health of the population has not yet been investigated in depth in Sweden, but a few studies have been published. A longitudinal study on 1071 older adults, aged 65-71 years, found that mental well-being remained stable or was even higher in the early days of the pandemic compared to previous years [ 1 ]. A cross-sectional online survey of 1212 adult volunteers showed high levels of depression, anxiety, and insomnia but no comparison could be made with the situation before the COVD-19 outbreak [ 2 ]. An early study in the UK showed that the prevalence of depression and anxiety increased, especially among young adults, immediately after the first lockdown [ 3 ]. In Sweden, it was expressed that, based on past experiences of economic crises, it is likely that the COVD-19 pandemic will lead to a rise in mortality in the future [ 4 ]. This is because mass unemployment leads to increased mortality in the population, including mortality from alcohol-related diseases, suicide, and cardiovascular diseases, especially among men with low socioeconomic status [ 5 ].

The negative effects of the pandemic on mental health may arise from social measures such as quarantine and lockdown, fear of COVID-19 disease and lifestyle changes [ 6 , 7 ]. In addition, some specific population groups such as young people, the elderly and people with learning disabilities and mental disabilities may be more affected than others [ 7 ]. The WHO and the UN have also highlighted the impact of the pandemic on the mental health of the population and the need to invest in health promotion and prevention in addition to health interventions [ 8 , 9 ].

Mental health is strongly linked to the individual’s living conditions and lifestyle habits [ 10 , 11 ]. The recommendations to the public made by the authorities due to the COVID-19 pandemic called on people to reduce their social contacts and those over 70 years of age were recommended to refrain from seeing people outside their own family. However, social relations are in many ways important for mental health [ 12 ]. Social support is a protective factor that can act as a buffer in psychosocial crisis situations or pressures. Furthermore, involuntary loneliness has been shown to have a strong link to depression among the elderly [ 13 ]. In addition to social relations, economic factors have a major impact on mental health. Those with financial difficulties have more mental health problems and depression [ 14 , 15 ]. Recipients of financial assistance and unemployed young adults have a higher incidence of mental health problems than others [ 16 ]. Other factors strongly linked to mental ill-health are physical inactivity, daily smoking, and obesity [ 17 , 18 , 19 ].

Mental health is also associated with physical health. This is especially true for musculoskeletal disorders that are often work-related and symptoms of overexertion. Psychological factors such as stress and anxiety are also assumed to be related to musculoskeletal pain. Anxiety, nervousness, and experiences of mental stress increase muscle tension which contributes to pain, especially in the neck and shoulders [ 20 ].

Population surveys are commonly used to measure living conditions, lifestyle habits and health in the general population. The answers from persons who respond early or late, that is before and after a first reminder to a survey questionnaire tend, however, to differ in several ways [ 21 ]. For example, non-native persons, those with only pre-secondary education and younger age groups are more often late respondents. Furthermore, younger people and people with low levels of education can more often be reached by telephone follow-ups of non-respondents [ 22 , 23 ]. We observed in a large survey in Sweden, that it was somewhat more common with good health as well as being physically active and having trust in others among those who responded early compared to those who responded late [ 21 ]. However, anxiety and nervousness were somewhat more common among those with late responses. These differences persisted even when age was taken into account.

A panel of experts on mental health in the UK published a recommendation for mental health research in Lancet Psychiatry in the context of the COVID-19 pandemic [ 24 ] and called for high-quality data and integration of different perspectives. Another group also emphasized the importance of monitoring mental disorders as well as risk factors such as unemployment, economic difficulties, alcohol consumption, and lack of social support in the population [ 25 ]. Several studies on the adverse effects of the pandemic on mental health and risk factors among adults, for example in Sweden [ 2 ], Canada [ 26 ] and Australia [ 27 ] were published after the first wave of the pandemic. However, these were usually conducted only after the outbreak of the pandemic and based on questionnaires distributed via social media, leading to self-selection, and have therefore probably exaggerated the effects of the pandemic [ 28 ]. Since then, many more studies have been published, including a review on the mental health effects of the pandemic [ 29 ] and a rapid review on the cardiovascular risk factors [ 30 ]. Neither of these reviews included, however, studies from Sweden. In addition, as Freiberg et al. [ 30 ] indicated, there is a high number of epidemiological studies on the impact of COVID-19 lockdown measures on modifiable cardiovascular risk factors, but only a few have used probability sampling methods. Epidemiologically robust methods, such as population studies based on random population sampling and the use of exactly the same questions before and after the outbreak of the pandemic are therefore of great value.

The aim of this study was to highlight mental and physical health as well as living conditions and lifestyle habits in the adult population before and after the COVID-19 outbreak in one county in Sweden by comparing early and late respondents to the public health survey “Health on equal terms?” carried out in February-May 2020.

The study is based on data from the population survey “Health on equal terms?” conducted in collaboration with the Public Health Agency of Sweden [ 31 ]. The national survey started in 2004 and has been carried out every two years since 2016 to monitor the health of the population in Sweden. The age group addressed is 16–84 years. The sample frame is the total population register at Statistics Sweden, the statistical administrative authority in Sweden, covering all inhabitants in the country. The national simple random sample in 2020 included 40,000 persons.

The present study is based on data from one county (Värmland) where an extended simple random sample was drawn. In total, the questionnaire was sent to 5091 persons in the county and 2273 individuals answered the questionnaire giving an overall response rate of 45%. The questionnaire was postal but could also be answered online. Data collection was discontinued after two postal reminders. In Värmland county, the first COVID-19 cases were reported on 6th March 2020 [ 31 ]. To define those who replied before and after the COVID-19 outbreak in Sweden the respondents were divided into early ( n  = 1711) and late ( n  = 562) respondents, i.e. those responding between 3th February and 11th March 2020, and those responding between 12th March and 5th May, respectively. The date 11th March coincided with posting the first reminder of the survey.

Värmland county is situated in the west of Mid-Sweden, bordering to Norway, and comprises about 282,000 inhabitants. It includes one bigger city with over 90,000 inhabitants and 15 smaller municipalities. The incidence of COVID-19 was lower in Värmland than in Sweden in general during March-May 2020 and by the last week in May 533 persons had been diagnosed with COVID-19 in Värmland [ 31 ].

The measures taken to combat the COVID-19 pandemic in Sweden included e.g. recommendations to keep distance to other people, to wash hands often, to stay at home when having symptoms of flu, to avoid travelling abroad and unnecessary travelling in Sweden, to avoid public places with crowds, and to work from home when possible. Those over 70 years of age were recommended to refrain from seeing people outside their own family. In the end of March, public gatherings of more than 50 persons were forbidden. No total lockdown was, however, instituted in Sweden.

To explore whether the results observed in 2020 are due to the COVID-19 pandemic, the same analyses were run in the corresponding “Health on equal terms?” survey which was carried out between 28th February and 18th June 2018. In total, 2142 persons aged 16-84 years responded to the survey in Värmland county with an overall response rate 42%. Out of these, 1660 individuals responded before (early respondents) and 482 after (late respondents) the first reminder sent on 10th April 2018.

Confounding variables

Information on gender, age, level of education and country of birth are based on register data from Statistics Sweden. Educational level was categorised into three levels: compulsory education, secondary education, and postsecondary education. Country of birth was dichotomized into those born in Sweden and those born outside Sweden.

Outcome variables

Living conditions.

Social support was measured with the question “Do you have anyone you can share your innermost feelings with and confide in?” (yes/no).

Economic difficulties were estimated with the question “During the last 12 months, have you ever had difficulty in managing the regular expenses for food, rent, bills etc.?”. The response options were “no”, “yes, once”, “yes, more than once” where the last two categories were combined to yes.

Trust in other people was measured with the question “Do you think that, in general, people can be trusted?” (yes/no). Employed people were defined as being worried about losing their job if they answered “yes” to the question “Are you worried about losing your job in the coming year?”

Lifestyle factors

Two questions for measuring physical activity were used. The first question was: How much time do you spend in a normal week on physical training that leaves you out of breath – for example running, fitness training, or ball sports? The response options were: 0 min/no time; less than 30 min; 30–59 min (0.5–1 h); 60–89 min (1–1.5 h); 90–119 min (1.5–2 h); 2 h or more. The second question was: How much time do you spend in a normal week on daily activities – for example walking, cycling, or gardening? Count all time together (at least 10 min at a time). The response options were: 0 min; less than 30 min; 30–59 min (0.5–1 h); 60–89 min (1–1.5 h); 90–149 min (1.5–2.5 h); 150–299 min (2.5–5 h); 5 h or more. These questions are used to measure whether the respondent reaches 150 activity minutes per week as recommended by the WHO. The number of minutes from the physical training and daily activities were summed together, with the number from the first variable counting double [ 32 ].

Sitting duration was asked with the question “How much do you sit during a normal day, not counting sleep?” The answer categories were dichotomised into those who sit less than 10 h and those who sit at least 10 h a day.

Smoking was measured using the question “Do you smoke” (“no”, “yes, sometimes”, “yes, daily”).

Alcohol consumption was measured using Alcohol Use Disorders Identification Test-C (AUDIT-C). AUDIT-C is a widely used and validated screening instrument of alcohol use. It comprises three questions on the frequency and quantity of alcohol consumption. We used the following cut-offs for risk-drinker: 6 or more points in men and 5 or more points in women [ 32 ].

The following variables were used to measure the respondents’ health [ 32 ]. Self-rated health (SRH) was measured with the question “How would you describe your health in general?”. Response options were very good, good, fair, poor and very poor. In the statistical analysis the options were dichotomised into good (very good or good) and poorer than good (fair, poor or very poor) SRH.

Illnesses were measured with the following question: Do you have any of the following illnesses (with answer options No; Yes, but no discomfort; Yes, minor discomfort; Yes, severe discomfort)? Illnesses included high blood pressure, and the last three categories were combined to Yes.

Symptoms were derived from the question: Do you have any of the following discomforts or symptoms? These included “aches in the shoulders or neck”, “sleeping difficulties” and “anxiety or worry”. The answer categories were No; Yes, minor discomfort and Yes, severe discomfort, where the two latter categories were combined to Yes.

Stress was measured with the question “Do you feel stressed at present? By stressed, we mean a condition where you feel tense, restless, nervous, uneasy or unable to concentrate.” The answer options were Not at all; To some extent; Quite a lot and Very much, where the last three options were defined as having stress.

Ethical considerations

The study followed the Swedish guidelines for studies in social sciences and humanities, in accord with the Declaration of Helsinki and the data are protected by the law of official statistics. The participants were informed that completed questionnaires would be linked to the Swedish official registries through personal identification numbers, to access registry information on gender, age, country of birth and educational level. The respondents thus gave their informed consent to the linking of registry data. The personal identification numbers were deleted before the data was delivered to Region Värmland. Statistics Sweden carried out the sampling, data collection and linkage with registry data and delivered the de-identified data. The study was approved by the Swedish Ethical Review Authority (Dnr 2020–04202).

Statistical analysis

Differences in the distribution of background characteristics and SRH between early and late respondents were tested using chi-square statistics. Difference in mean age was tested using independent samples t-test. P -values < 0.05 were considered as statistically significant. The differences in living conditions, lifestyle habits, and health between early and late respondents were studied using multivariate binary logistic regression, with early/late response as the independent variable (reference category = early response), adjusting for background characteristics gender, age group, educational level, and country of birth. The results are reported as odds ratios (OR) and 95% confidence intervals (95% CI) for each living condition, lifestyle habit and health condition as outcome at a time. All analyses were conducted in IBM SPSS Statistics, version 26.

Table  1 shows the background characteristics of the study population among early and late respondents. Late respondents were younger than early respondents (mean age 53.5 and 58.2 years, respectively, p  < .05) and they had a larger proportion of persons born outside Sweden than early respondents. There were no statistically significant differences in gender or level of education between the respondent groups.

Some differences in living conditions, lifestyle factors and health between the two groups were observed (Table  2 ). Late respondents had more economic difficulties, had lower trust in other people, and were more often worried about losing their job than early respondents. There were no statistically significant differences between the groups regarding lifestyle factors. Sleeping difficulties were more common among early respondents whereas stress was more common among late respondents. Otherwise no statistically significant differences in health problems were found.

Due to the differences in age and country of birth between the groups, multivariate logistic regression analyses were carried out adjusting for gender, age group, educational level, and country of birth (last column in Table 2 ). When adjusting for these background characteristics, statistically significant differences between early and late respondents remained for economic difficulties and worry about losing one’s job, which were more common among late respondents, and for sleeping difficulties, which were more common among early respondents. There were no differences in other living conditions nor in lifestyle factors. Self-rated health, high blood pressure, aches in shoulders or neck, anxiety or worry and stress did not differ between the groups when adjusting for background characteristics.

When the same multivariate logistic regression analyses were carried out in the corresponding survey in 2018, no statistically significant differences were observed between early and late respondents for lifestyle factors or health variables (see Supplementary Table S 1 , Additional file  1 ). For living conditions, the only statistically significant association was found for economic difficulties (OR: 1.64; 95% CI: 1.20-2.24). The prevalence of being worried about losing one’s job did not differ between early and late respondents (OR: 1.03; 95% CI: 0.64-1.65). The same applies to sleeping difficulties (OR: 0.84; 95% CI: 0.67-1.05).

In this study, very few differences were observed between early and late respondents in 2020 regarding living conditions, lifestyle factors and health. However, in the 2020-survey, it was more common among the late respondents to be worried about losing their job, and more common among the early respondents to report sleeping difficulties. These differences could not be seen in the corresponding survey in 2018.

The COVID-19 pandemic hit hard in Sweden in spring 2020 and until the last week in May 4499 people, predominantly persons over 70 years, had lost their lives and 2088 persons had been or were being treated in intensive care [ 31 ]. The short-term public health consequences of the COVID-19 pandemic and the restrictions related to it were however rather small at the population level in the present study. This is in line with the findings of the review of Prati et al. [ 29 ] who showed that the psychological impact of COVID-19 lockdowns was small in magnitude and highly heterogeneous, and no change for instance in social support was observed. Nevertheless, there can be subgroups where the impact has been detrimental. For example, Pierce et al. [ 33 ] found that even though the mental health of most UK adults remained resilient or returned to pre-pandemic levels between April and October 2020, about one in nine had a deteriorating or consistently poor mental health. Those in the deteriorating mental health group were more likely to be women, younger, without a partner, and have a previous mental illness [ 33 ]. The review of Freiberg et al. [ 30 ] reported, in turn, that physical activity decreased whereas sedentary behavior and alcohol consumption increased during the COVD-19 lockdown. But even though only studies using probability sampling were included in the review there were methodological shortcomings in many of these studies [ 30 ]. The only direct consequence of the pandemic in the present study seems to have been a rise in the proportion who worry about losing their job. Since worrying about losing one’s job is associated with mental health problems [ 9 ], it can be assumed that if this increase persists or continues, it will have a detrimental effect for the future mental health of the population. The proportion of persons having economic difficulties was also higher among the late respondents, but since similar findings were observed in the 2018 study, it is improbable that the difference in 2020 was due to the COVID-19 pandemic. Furthermore, this finding underlines the point that researchers should be observant and not to draw hasty conclusions that study results are due to the pandemic just because they occur during the same time period. Moreover, since early and late respondents differ from each other in many health-related aspects, it is important to adjust for known background characteristics and take the period of time into account.

The result that sleeping difficulties were more common among early than late respondents is somewhat puzzling. Similar findings were not observed in the 2018 study. An increase in the proportion who worry about losing their job suggests that an increase in sleeping difficulties may have been more likely. A cross-sectional study in Reggio Emilia in Italy, based on 1826 individuals, found that the first lockdown may have worsened the quality of sleep [ 34 ]. On the other hand, a study based on smartphone data in the US and 16 European countries found that the subjects increased their sleep duration but delayed their sleep onset during the COVID-pandemic in comparison to before the pandemic [ 35 ]. In Sweden, there was no total lockdown and the result that the mental well-being remained stable or was even higher after the outbreak of the pandemic among Swedish elderly [ 1 ] suggests that the changes in health are not necessarily always as expected. In addition, we did not find any increase in anxiety or worry or in stress. One, although somewhat improbable, explanation for the fact that late respondents reported less sleeping difficulties could be that an increasing number of employees were able to better control their working hours since they were working from home. This could perhaps contribute to better sleep. The decrease in sleeping difficulties may, of course, also be a spurious finding.

The response rate in our study was somewhat higher in 2020 (45%) than in 2018 (42%). This may have been due to the pandemic, increased interest in health issues, in recognizing the sender, the National Public Health Agency of Sweden, which had a press conference nearly every day at the beginning of the pandemic, or just because of chance.

Our sample was rather small, and we could not differentiate any groups within the two categories. It is possible that some groups have been affected by the COVID-19 pandemic more than others, for example those who have lost their jobs or persons over 70 years who were recommended to social isolation. It has been suggested that the pandemic will lead to increased inequalities in health [ 36 ]. In this study we were not able to assess health inequalities and changes in them. Also, the time frame was short and the effect of the second wave during the late autumn 2020 and other long-term consequences are not yet known. The survey was also limited to one county, where the number of cases treated in hospital care in relation to population was rather limited compared to for example the county of Stockholm [ 31 ]. The restrictions due to the pandemic were, however, similar.

The strength of our study is that it is based on a random population sample and the same questionnaire was used both by the early and late respondents. Another advantage is that we could compare the results directly with the survey carried out in 2018 so that false conclusions could be avoided. Several studies on the adverse effects of the pandemic on mental health and risk factors among adults have already been published [ 2 , 26 , 27 ]. However, it has been noted that these have usually been conducted only after the outbreak of the COVID-19 pandemic and been based on questionnaires distributed via social media, leading to self-selection and probable exaggerated effects of the pandemic [ 28 , 29 , 30 ]. Many papers on the pandemic have been published in public health journals, and even though more studies using robust methodology have been published since the early days of the pandemic, papers showing data based on robust methods have been scarce [ 29 , 30 , 37 ]. In addition, the results can vary between countries and the time of the study. For example, a study from Austria showed that COVID-19 restriction measures resulted in increased, but only on short-term, levels of loneliness among older adults during the lockdown [ 38 ].

In conclusion, there was a statistically significant difference between early and late respondents in the study population in 2020 for worry about losing one’s job that could not be observed in the 2018-material. It is probable that this is attributable to the outbreak of the COVID-19 pandemic. The observed decrease in sleeping difficulties remains more puzzling. More research on the short- and long-term public health consequences of the pandemic in the general population and in different subgroups as well differences between populations, using robust data and methods, is thus needed.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality and regulations under the Swedish law (the Public and Privacy Act 2009: 400, Chapter 24, Section 8), but descriptive data in table form are available from the corresponding author on reasonable request.

Abbreviations

Confidence interval

Alcohol Use Disorders Identification Test-C

Self-rated health

World Health Organization

Kivi M, Hansson I, Bjälkebring P. Up and about: older adults' well-being during the COVID-19 pandemic in a Swedish longitudinal study. J Gerontol B Psychol Sci Soc Sci. 2021;76:e4–9.

Article   Google Scholar  

McCracken L, Badinlou F, Buhrman M, Brocki K. Psychological impact of COVID-19 in the Swedish population: depression, anxiety, and insomnia and their associations to risk and vulnerability factors. Eur Psychiatry. 2020;63:E81.

The Guardian Rise in depression and anxiety day after UK lockdown announced – study 31 March 2020. https://www.theguardian.com/world/2020/mar/31/rise-in-depression-and-anxiety-day-after-uk-lockdown-announced-study-coronavirus . Accessed 20 September 2021.

SVT. Arbetslösa riskerar att dö i förtid. [The unemployed are at risk to die prematurely.] 26 March 2020. https://www.svt.se/nyheter/inrikes/arbetslosa-riskerar-att-do-i-fortid . Accessed 20 September 2021.

Vågerö D, Garcy AM. Does unemployment cause long-term mortality? Selection and causation after the 1992-96 deep Swedish recession. Eur J Pub Health. 2016;26:778–83.

Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912–20.

Article   CAS   Google Scholar  

Karolinska Institutet. Covid-19: Resurser för psykiskt välbefinnande. [Covid-19: Resources for psychological well-being.] Nationellt Centrum för Suicidforskning och Prevention, 2020. https://ki.se/nasp/covid-19-resurser-for-psykiskt-valbefinnande . Accessed 20 September 2021.

World Health Organization. Mental health & COVID-19. WHO, 2020. https://www.who.int/teams/mental-health-and-substance-use/covid-19 . Accessed 20 September 2021.

United Nations. Policy brief: COVID-19 and the Need for Action on Mental Health. United Nations, 13 May 2020. https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf . Accessed 20 September 2021.

Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al. Social determinants of mental disorders and the sustainable development goals: a systematic review of reviews. Lancet Psychiatry. 2018;5:357–69.

Molarius A, Berglund K, Eriksson C, Eriksson HG, Lindén-Boström M, Nordström E, et al. Mental health symptoms in relation to socio-economic conditions and lifestyle factors-a population-based study in Sweden. BMC Public Health. 2009;9:302.

Cooper H, Arber S, Fee L, Ginn J. The influence of social support and social capital on health. A review and analysis of British data. London: Health Education Authority; 1999.

Google Scholar  

Erzen E, Çikrikci Ö. The effect of loneliness on depression: a meta-analysis. Int J Soc Psychiatry. 2018;64:427–35.

Molarius A, Granström F. Educational differences in psychological distress? Results from a population-based sample of men and women in Sweden in 2012. BMJ Open. 2018;8:e021007.

Ahnquist J, Wamala S. Economic hardship in adulthood and mental health in Sweden. The Swedish National Public Health Survey 2009. BMC Public Health. 2011;11:788.

The Public Health Agency of Sweden. Ojämlikheter i psykisk hälsa. Kunskapssammanställning. [Inequalities in mental health. Knowledge overview.] Stockholm; Folkhälsomyndigheten, 2019.

Dinas PC, Koutedakis Y, Flouris AD. Effects of exercise and physical activity on depression. Ir J Med Sci. 2011;180:319–25.

Banzer R, Haring C, Buchheim A, Oehler S, Carli V, Wasserman C, et al. Factors associated with different smoking status in European adolescents: results of the SEYLE study. Eur Child Adolesc Psychiatry. 2017;26:1319–29.

Scott KM, Bruffaerts R, Simon GE, Alonso J, Angermeyer M, de Girolamo G, et al. Obesity and mental disorders in the general population: results from the world mental health surveys. Int J Obesity. 2008;32:192–200.

Melin B, Lundberg U. A biopsychosocial approach to work-stress and musculoskeletal disorder. J Psychophysiol. 1997;11:238–47.

Bortfallsanalys. Liv & hälsa i Mellansverige 2017. [Non-response analysis. Life & health in Mid-Sweden 2017.] Rapportserie utgiven i samverkan mellan regionerna i Uppsala, Sörmlands, Västmanlands, Värmlands och Örebro län, 2019. https://www.regionvarmland.se/globalassets/vardgivarwebb/samverkan-avtal-och-vardval/folkhalsa-och-samhallsmedicin/folkhalsa-i-siffror/bortfallsanalys_liv_och_halsa_i_mellansverige_2017.pdf . Accessed 20 September 2021.

Lindén-Boström M, Persson C. A selective follow-up study on a public health survey. Eur J Pub Health. 2013;23:152–7.

Helakorpi S, Mäkelä P, Holstila A, Uutela A, Vartiainen E. Can the accuracy of health behaviour surveys be improved by non-response follow-ups? Eur J Pub Health. 2015;25:487–90.

Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry. 2020;7:547–60.

Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, et al. COVID-19 suicide prevention research collaboration. Suicide risk and prevention during the COVID-19 pandemic. Lancet. Psychiatry. 2020;7:468–71.

PubMed   Google Scholar  

Lesser IA, Nienhuis CP. The impact of COVID-19 on physical activity behaviour and well-being of Canadians. Int J Environ Res Public Health. 2020;17:3899.

Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Twaite TL, et al. Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health. 2020;17:4065.

Hotopf M, Bullmore E, O'Connor RC, Holmes EA. The scope of mental health research during the COVID-19 pandemic and its aftermath. Br J Psychiatry. 2020;217:540–2.

Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51:201–11.

Freiberg A, Schubert M, Starke KR, Hegewald J, Seidler A. A rapid review on the influence of COVID-19 lockdown and quarantine measures on modifiable cardiovascular risk factors in the general population. Int J Environ Res Public Health. 2021;18:8567.

The Public Health Agency of Sweden. Covid-19. Bekräftade fall i Sverige. [Covid-19. Confirmed cases in Sweden]. https://www.folkhalsomyndigheten.se/smittskydd-beredskap/utbrott/aktuella-utbrott/covid-19/statistik-och-analyser/bekraftade-fall-i-sverige/ . Accessed 20 September 2021.

The Public Health Agency of Sweden. Hälsa på lika villkor? Nationella folkhälsoenkäten [Health on equal terms? The national public health survey]. http://www.folkhalsomyndigheten.se . Accessed 20 September 2021.

Pierce M, McManus S, Hope H, Hotopf M, Ford T, Hatch SL, et al. Mental health responses to the COVID-19 pandemic: a latent class trajectory analysis using longitudinal UK data. Lancet Psychiatry. 2021;8:610–9.

Costi S, Paltrinieri S, Bressi B, Fugazzaro S, Giorgi Rossi P, Mazzini E. Poor sleep during the first peak of the SARS-CoV-2 pandemic: a cross-sectional study. Int J Environ Res Public Health. 2021;18:306.

Lee PH, Marek J, Nálevka P. Sleep pattern in the US and 16 European countries during the COVID-19 outbreak using crowdsourced smartphone data. Eur J Pub Health. 2021;31:23–30.

Burström B, Tao W. Social determinants of health and inequalities in COVID-19. Eur J Pub Health. 2020;30:617–8.

Odone A, Galea C, Stuckler D, Signorelli C. The first 10 000 COVID-19 papers in perspective: are we publishing what we should be publishing? Eur J Pub Health. 2020;30:849–50.

Stolz E, Mayerl E, Freidl W. The impact of COVID-19 restriction measures on loneliness among older adults in Austria. Eur J Pub Health. 2021;31:44–9.

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Acknowledgements

We thank Bernard Swift and Anna Swift-Johannison for helpful comments on the English language.

Open access funding provided by Karlstad University. The survey was funded by Region Värmland.

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Anu Molarius

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Both authors (AM and CP) participated in designing the study and in interpreting the results. AM drafted the manuscript and conducted the statistical analyses. Both authors contributed to writing and revising the manuscript and have read and approved the final version of the manuscript.

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Correspondence to Anu Molarius .

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The study was approved by the Swedish Ethical Review Authority (Dnr 2020–04202). The respondents gave their informed consent to the linking of registry data by answering the questionnaire. The dataset includes subjects who are 16-17 years old, but according to the Swedish regulations they do not need an informed consent from a parent or guardian to answer the questionnaire. The study followed the Swedish guidelines for studies in social sciences and humanities, in accord with the Declaration of Helsinki and the data are protected by the law of official statistics.

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Supplementary Information

Additional file 1: table s1.

. Living conditions, lifestyle factors and health among early and late respondents 16-84 years in 2018 and adjusted odds ratios (with 95% confidence intervals in parenthesis) for living conditions, lifestyle factors and health among late respondents compared to early respondents.

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Student Opinion

How Did the Covid-19 Pandemic Affect You, Your Family and Your Community?

This week is the fourth anniversary of the pandemic. What are your most lasting memories? How did it reshape your life — and the world?

By Jeremy Engle

It has been four years since the World Health Organization declared Covid-19 a global pandemic on March 11, 2020. The New York Times writes of the anniversary:

Four years ago today, society began to shut down. Shortly after noon Eastern on March 11, 2020, the World Health Organization declared Covid — or “the coronavirus,” then the more popular term — to be a global pandemic. Stocks plummeted in the afternoon. In the span of a single hour that night, President Donald Trump delivered an Oval Office address about Covid, Tom Hanks posted on Instagram that he had the virus and the N.B.A. announced it had canceled the rest of its season. It was a Wednesday, and thousands of schools would shut by the end of the week. Workplaces closed, too. People washed their hands frequently and touched elbows instead of shaking hands (although the C.D.C. continued to discourage widespread mask wearing for several more weeks). The worst pandemic in a century had begun.

For some people, the earliest days of the pandemic may feel like a lifetime ago; for others, it may feel like just yesterday. But for all of us Covid has indelibly changed our lives and the world. What do you remember about the earliest days of the pandemic? When did it first hit home for you? How did it affect you, your family and your community? What lessons did you learn about yourself and the world?

In “ Four Years On, Covid Has Reshaped Life for Many Americans ,” Julie Bosman writes that while the threat of severe illness and death has faded for many people, the pandemic’s effects still linger:

Jessie Thompson, a 36-year-old mother of two in Chicago, is reminded of the Covid-19 pandemic every day. Sometimes it happens when she picks up her children from day care and then lets them romp around at a neighborhood park on the way home. Other times, it’s when she gets out the shower at 7 a.m. after a weekday workout. “I always think: In my past life, I’d have to be on the train in 15 minutes,” said Ms. Thompson, a manager at United Airlines. A hybrid work schedule has replaced her daily commute to the company headquarters in downtown Chicago, giving Ms. Thompson more time with her children and a deeper connection to her neighbors. “The pandemic is such a negative memory,” she said. “But I have this bright spot of goodness from it.” For much of the United States, the pandemic is now firmly in the past, four years to the day that the Trump administration declared a national emergency as the virus spread uncontrollably. But for many Americans, the pandemic’s effects are still a prominent part of their daily lives. In interviews, some people said that the changes are subtle but unmistakable: Their world feels a little smaller, with less socializing and fewer crowds. Parents who began to home-school their children never stopped. Many people are continuing to mourn relatives and spouses who died of Covid or of complications from the coronavirus. The World Health Organization dropped its global health emergency designation in May 2023, but millions of people who survived the virus are suffering from long Covid, a mysterious and frequently debilitating condition that causes fatigue, muscle pain and cognitive decline . One common sentiment has emerged. The changes brought on by the pandemic now feel lasting, a shift that may have permanently reshaped American life.

As part of our coverage of the pandemic’s anniversary, The Times asked readers how Covid has changed their attitudes toward life. Here is what they said:

“I’m a much more grateful person. Life is precious, and I see the beauty in all the little miracles that happen all around me. I’m a humbled human being now. I have more empathy and compassion towards everyone.” — Gil Gallegos, 59, Las Vegas, N.M. “The pandemic has completely changed my approach to educating my child. My spouse and I had never seriously considered home-schooling until March 2020. Now, we wouldn’t have it any other way.” — Kim Harper, 47, Clinton, Md. “I had contamination O.C.D. before the pandemic began. The last four years have been a steady string of my worst fears coming true. I never feel safe anymore. I know very well now that my body can betray me at any time.” — Adelia Brown, 23, Madison, Wis. “I don’t take for granted the pleasure of being around people. Going to a show, a road trip, a restaurant, people watching at the opera. I love it.” — Philip Gunnels, 66, Sugar Land, Texas “My remaining years are limited. On the one hand, I feel cheated out of many experiences I was looking forward to; on the other hand, I do not want to live my remaining years with long Covid. It’s hard.” — Sandra Wulach, 77, Edison, N.J.

Students, read one or both of the articles and then tell us:

How did the Covid-19 pandemic affect you, your family and your community? How did it reshape your life and the world? What are your most lasting memories of this difficult period? What do you want to remember most? What do you want to forget?

How did you change during this time? What did you learn about yourself and about life? What do you wish you knew then that you know now?

Ms. Bosman writes that some of the people she interviewed revealed that four years after the global pandemic began, “Their world feels a little smaller, with less socializing and fewer crowds.” However, Gil Gallegos told The Times: “I’m a much more grateful person. Life is precious, and I see the beauty in all the little miracles that happen all around me. I’m a humbled human being now. I have more empathy and compassion towards everyone.” Which of the experiences shared in the two articles reminded you the most of your own during and after the pandemic and why? How did Covid change your overall outlook on life?

“The last normal day of school.” “The nursing home shut its doors.” “The bride wore Lululemon.” These are just a few quotes from “ When the Pandemic Hit Home ,” an article in which The Times asked readers to share their memories of the world shutting down. Read the article and then tell us about a time when the pandemic hit home for you.

In the last four years, scientists have unraveled some of the biggest mysteries about Covid. In another article , The Times explores many remaining questions about the coronavirus: Are superdodgers real? Is Covid seasonal? And what’s behind its strangest symptoms? Read the article and then tell us what questions you still have about the virus and its effects.

How do you think history books will tell the story of the pandemic? If you were to put together a time capsule of artifacts from this era to show people 100 years from now, what would you include and why? What will you tell your grandchildren about what it was like to live during this time?

Students 13 and older in the United States and Britain, and 16 and older elsewhere, are invited to comment. All comments are moderated by the Learning Network staff, but please keep in mind that once your comment is accepted, it will be made public and may appear in print.

Find more Student Opinion questions here. Teachers, check out this guide to learn how you can incorporate these prompts into your classroom.

Jeremy Engle joined The Learning Network as a staff editor in 2018 after spending more than 20 years as a classroom humanities and documentary-making teacher, professional developer and curriculum designer working with students and teachers across the country. More about Jeremy Engle

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• Published: 06 July 2020

COVID and CopMich: comparing and contrasting COVID-19 experiences in the USA and Scandinavia

• Juan J. Andino 1 ,
• James M. Dupree   ORCID: orcid.org/0000-0002-4290-9648 1 ,
• Christian F. S. Jensen 2 ,
• Ganesh S. Palapattu 1 ,
• Jens Sønksen 2 &
• Daniela Wittmann   ORCID: orcid.org/0000-0002-9201-7269 1  

Nature Reviews Urology volume  17 ,  pages 493–498 ( 2020 ) Cite this article

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On 11 March 2020, the World Health Organization declared SARS-CoV-2 and its associated disease, COVID-19, a global pandemic. Across the world, governments took action to slow the spread and hospitals rushed to accommodate an influx of patients with this highly infectious and lethal disease. The urology departments in Ann Arbor, Michigan, USA, and Herlev and Gentofte, Copenhagen, Denmark — which are linked by the pre-existing CopMich Collaborative — had to respond with massive changes to the organization, staffing and workload of their teams. In this Viewpoint, authors from different urological subspecialties and at different career stages reflect on their experiences during the pandemic. Although their countries’ responses to the COVID-19 pandemic differed radically, the similarities between the responses in Copenhagen and Michigan demonstrate the universal characteristics of medicine and the value of teamwork, flexibility and collaboration.

The contributors

Juan J. Andino is a third-year urology resident at the University of Michigan. He completed his undergraduate and medical degrees, and an MBA at the University of Michigan. Dr Andino is interested in telehealth and health policy and hopes to work at the intersection of these fields to optimize the delivery of urological care.

James M. Dupree is an Associate Professor of Urology at the University of Michigan. He completed his residency at Northwestern University and his fellowship in Male Reproductive Medicine and Surgery at Baylor College of Medicine. He also completed a Health Policy Fellowship with the American College of Surgeons. Dr Dupree specializes in the advanced treatment of male infertility, and his research focuses on male infertility and reproductive health policy. Dr Dupree is also the Ambulatory Care Clinical Chief for Urology at the University of Michigan.

Christian Fuglesang S. Jensen received his medical degree from the University of Copenhagen in 2015 and is currently enrolled as a PhD trainee working with male infertility at the Department of Urology, Herlev and Gentofte Hospital. Dr Jensen has previously worked at the Department of Urology, University of Michigan, performing research into andrology and male infertility. Dr Jensen serves as chair on the ESSM Scientific Sub-Committee for new technologies and sexual function and is a co-founder and member of the Core Unit of the CopMich Collaborative.

Ganesh S. Palapattu is the George F. and Sandy G. Valassis Professor and Chair of the Department of Urology at the University of Michigan. He attended the University of Texas at Austin where he earned a Bachelor of Arts degree in Humanities and then Baylor College of Medicine in Houston, Texas, where he earned his medical degree. Subsequently, Dr Palapattu completed his surgical internship, urology training and chief residency in urology at the David Geffen School of Medicine at UCLA followed by a laboratory research fellowship in Urologic Oncology at the Johns Hopkins Hospital Brady Urological Institute. His clinical interest is in the evaluation and management of men with prostate and kidney cancer.

Jens Sønksen received his medical degree from the University of Copenhagen in 1988 and earned his PhD and Doctor of Medical Science in 1995 and 2003, respectively. He is currently Professor of Urology at the University of Copenhagen and Head of the Urological Research Center and Section of Andrology, Herlev and Gentofte Hospital, Denmark. Dr Sønksen is currently serving as Adjunct Secretary General of the European Association of Urology and is a co-founder and member of the Core Unit of the CopMich Collaborative.

Daniela Wittmann received her BA Hons at Keele University, Keele, UK, her Master’s in Social Work at Simmons College School of Social Work, Boston, MA and her PhD at Michigan State University. She is an Associate Professor in the Department of Urology and Adjunct Associate Professor at the School of Social Work at the University of Michigan. Dr Wittmann is a leading member of the Brandon Prostate Cancer Survivorship Program at the University of Michigan and serves as the Chair of the Mental Health Committee of the Sexual Medicine Society of North America. She is also a member of the Prostate Health Committee of the Urology Care Foundation.

What were the immediate changes in your institution in response to COVID-19?

Ganesh S. Palapattu. COVID-19 has proven to be a crisis like no other. When it became clear that the pandemic was headed our way, our health system rapidly strategized and deployed a series of measures to monitor and mitigate the oncoming health-care disaster. Almost immediately a command centre was created, composed of a small multidisciplinary group of individuals spanning clinical operations, infectious disease, epidemiology, supply chain, critical care and communications, among others. This group met daily during our peak, often twice a day, to assess the current status, plan for the immediate future and identify and solve problems. This group was also key in providing timely and informative updates to our health system and community. At the same time, a team of Michigan Medicine experts, alongside collaborators from around the country, developed Michigan-specific prediction models and liaised with adjoining health systems and local and state government and public health departments. Furthermore, space allocations were quickly re-arranged in the span of days to create a regional infectious containment unit (RICU) — a negative pressure unit comprising a substantial number of isolation rooms equipped with critical care medical equipment in compliance with CDC guidelines. As many of you know, the Detroit area was hit hard by COVID-19. I am proud to say that our health-care system responded to the call for help and provided critical surge capacity for patients and hospital systems in need. Truthfully, I can’t say enough positive things about how Michigan Medicine responded to the acute crisis. We anticipate having a baseline census of patients with COVID-19 in the hospital for the next 18 months or so, in addition to possible further waves of illness to come.

From a departmental perspective, we also rapidly organized and mobilized with the realization that COVID-19 was about to have an enormous impact in our area. We are fortunate to have nearly 50 full-time clinical faculty in our urology department, so this afforded us some flexibility. Borrowing from the Lombardy model, we created three squads composed of faculty, trainees and advanced practice providers (for example, nurse practitioners) from all major urological disciplines (oncology, endourology, neuropelvic–reconstructive, general and paediatric) and deployed them on a schedule of 1 week in-person care followed by 2 weeks of virtual care. The intention was to limit health-care worker exposure as much as possible and to allow appropriate recovery time while providing all necessary care. We halted all elective cases across all specialties during the peak and performed only emergency and urgent procedures. From a urological perspective, this approach meant performing surgery for symptomatic bladder cancer, large renal tumours with caval involvement and urgent stone cases. Many of our residents and advanced practice providers volunteered for general and intensive care unit care responsibilities and some were deployed in this way. We were lucky that the crisis never reached a point that required all of us to be re-deployed, owing to the positive impact of social distancing in our area as well as the tremendous contributions of our medical, surgical and anaesthesia colleagues at Michigan Medicine. Since mid-May, we have begun the surgical ramping up process in a deliberate and thoughtful manner to optimize patient and provider safety.

Juan J. Andino. Our institution and department responded swiftly. Elective surgeries were cancelled, and leadership across the institution helped the transition from in-person to virtual encounters, reserving clinic space, emergency room and inpatient wards for patients with urgent or emergency issues.

Drs Palapattu, Kraft and Ambani (Urology Chair, Program Director and Assistant Program Director, respectively) immediately worked with the chief residents to design a schedule focused on safety, reducing the risk of potential exposures and minimizing the use of PPE. We were initially divided into three groups — one group would divide up tasks in the hospital whereas the remaining two-thirds of residents worked virtually from home.

Residents absorbed multiple roles, covering consultations and inpatient care across our three main hospitals. Initially, this workload was manageable owing to the drop in volume from cancelled elective surgeries as well as the ability to address many clinical queries with e-consults. Telehealth was adopted for the inpatient hospital setting and when a physical examination was not likely to alter medical decision-making, recommendations were provided after a conversation and review of laboratory results and imaging 1 . However, as additional urgent procedures were being scheduled with increased testing capacity and operating room (OR) safety protocols, a clinically active cohort composed of one-third of the residents was no longer sufficient. We then transitioned to a two-team system — Blue and Maize — to enable more effective coverage of operating rooms, consultations and inpatient wards.

At this time, we are planning how to return to a new normal, in which residents go back to previously scheduled rotations with flexible coverage determined by clinical needs and OR availability. Masks are now required in all patient care areas and anyone entering the hospital is screened at every entrance for symptoms and given a mask if they don’t already have one. More widespread testing is enabling patients to be tested before scheduled surgery. Between this and Governor Gretchen Whitmer’s thoughtful approach and executive orders promoting social distancing, the numbers in the hospital have dropped from a peak of 229 on 16 April 2020 to 8 on 26 June 2020.

James M. Dupree. One of our first changes was to limit the number of patients coming to see us in clinic. We started by postponing clinic appointments for patients who were deemed to be at high risk of developing complications should they contract COVID-19, for example, immunosuppressed or elderly patients. Within about a week, we started postponing more patients, based on the urgency of their medical problems. We performed a similar triage for surgical cases and started postponing all but the most urgent urological surgeries, but we never closed our clinics or operating rooms completely and always cared for patients with urgent or emergency needs.

As we neared the peak of the COVID-19 patient surge, we prepared for the possibility of exceeding our hospital’s inpatient capacity. We planned to create a field hospital in a nearby university athletic facility to care for patients who were COVID-19-positive. The urology faculty were planning to staff this field hospital to provide general medical care for patients who were improving but were not yet ready for discharge home. Thankfully, the community’s social distancing measures prevented the COVID-19 patient volume from ever exceeding our hospital’s capacity and that field hospital never opened.

Jens Sønksen. The COVID-19 pandemic had immediate and profound consequences for the Danish Health system, including the Department of Urology at Herlev and Gentofte Hospital. Despite a well-functioning health-care system, no plan of action was prepared for a situation like this and the initial phase was filled with a lot of uncertainties and communication deficits between the government, health boards, hospital boards and department administration. Within a few days of Denmark’s lockdown on 11 March 2020, all elective surgery and outpatient clinic visits were cancelled or postponed and, if possible, replaced by telecommunications for diagnosis and follow-up monitoring. From one day to the next, the department was completely restructured, with doctors and nurses sent to COVID-19 test centres and COVID-19 wards and regular urology wards redesignated as isolation wards in preparation for the expected rise in the number of COVID-19 cases in Denmark. Every individual worked hard to ‘flatten the curve’ and enable the health system to cope with increasing COVID-19 cases. On a daily level, doctors could no longer meet at morning conferences, all large meetings (>10 persons) were cancelled and the teaching of medical students during clinical rotation was postponed, although virtual teaching programmes were soon established. We are now slowly opening and have restarted outpatient visits and elective surgery, whereas acute urology and cancer diagnostics and treatment have been ongoing during the entire period.

How did your institution respond to the COVID-19 pandemic?

Daniela Wittmann. There was an immediate move to clear the hospital to accommodate the COVID-19 patient influx. Urological surgeries were cancelled. I am a sex therapist in the prostate cancer survivorship programme and this meant that my sex therapy appointments with patients with prostate cancer post-op would diminish for a while. My clinic and my research office were closed and all work moved to virtual platforms. I have been working from home seeing patients in video visits and doing research online with meetings via Zoom. Both are quite manageable, although doing virtual sex therapy has its challenges. However, owing to the decreased clinical volume, I have had time to start a research project on patients’ and physicians’ responses to the delay in cancer care during the pandemic; I am glad to have a chance to engage with this difficult situation in a meaningful way.

J.M.D. I was impressed with the speed and flexibility of our institution’s response to the COVID-19 pandemic. Several weeks before the first case in Michigan, we created a centralized command centre to oversee institution-wide clinical operations. Once COVID-19 reached our state, we contracted our clinical sites, triaged our surgical cases and doubled our intensive care unit capacity. Many of these changes were enabled by our employment structure: the physicians, nurses, nurse practitioners, physician assistants and all the other members of the clinical workforce are employees of the institution, which helped us to respond in a coordinated fashion.

In addition, our medical group had recently implemented new layers of clinical leadership — including physicians, administrators and nurses — to oversee our clinics. These clinical leaders were instrumental in our response. There were instances of miscommunication or challenges with inconsistent decision-making, but these instances were rare, and the benefits of the clinical leadership triads were immense.

Christian Fugelsang S. Jensen. Denmark closed down on the evening of Wednesday 11 March 2020. Listening to the press briefing from the Prime Minister I realized how big an impact the COVID-19 pandemic would have on clinical research. The next day I could not go to work at the Urological Research Unit at Herlev and Gentofte Hospital and had to cancel all my patients’ visits and elective surgeries. I was in the final months of completing my PhD, a randomized surgical trial on sperm retrieval in men with non-obstructive azoospermia, but had to pause all related clinical activities. As part of my PhD, Professor Dana Ohl from the University of Michigan performs surgery with me on all study patients in Denmark, but the travel ban made this impossible. Currently, the travel ban is still in place, but we are working on possibilities for finishing the study and the PhD.

J.S. As Chair of Urology at the University of Copenhagen it was my responsibility to find alternatives for teaching medical students. We successfully established e-learning platforms with interactive sessions for discussion and we had to restrict clinical teaching at hospitals to limit the possible spread of COVID-19. For students on clinical rotations who normally have a real patient as part of their clinical urology examination, we replaced the patient with a urologist in the role of a patient and could then complete the exams.

What did your institution do, formally and informally, to provide support for faculty and staff during the COVID-19 pandemic?

G.S.P. The COVID-19 crisis revealed the true character of our department: compassionate and selfless. People looked out for one another and sought ways to provide support to those in need. One of our faculty in paediatric urology, Dr Courtney Streur, created the Daily (Uro)Flow, a spontaneous and voluntary daily email from a department member describing how they were coping with the crisis, often with funny anecdotes. Plenty of Zoom calls were had to maintain connectivity and provide updates. I know many faculty and staff who reached out to each other during the peak to lend support and check on each other. Our residency programme director, Dr Kate Kraft, met with all of our residents weekly via Zoom to check in and we maintained our weekly department conference schedule via video conference. As much as possible, we tried to remain connected.

J.M.D. I think everyone on our team felt scared, anxious and/or frustrated at various times during the pandemic. It was an unprecedented time. Our institution advertised counselling services that all faculty or staff could use. I took advantage of these counselling services in the heat of the pandemic and found them invaluable for reinforcing my ability to help to lead our department’s operational response. Living and working through this pandemic were powerful reminders that we need to take care of ourselves so that we can take care of others.

D.W. A number of supportive activities were organized by Michigan Medicine, including counselling for staff and faculty and information websites. Hospital system leadership provided daily updates about hospital census of patients with COVID-19, employee testing and infections. Weekly Town Halls were held for all employees with information about state and hospital statistics, workforce deployment, financial impact of the pandemic on the institution and Q and A opportunities. In the Department of Urology, the Chair provided weekly updates on issues relevant to the faculty, such as plans for potential deployment in the COVID-19 zones, organization of urology services, team organization with health-protective strategies, OR availability and financial impact of the pandemic. The departmental Wellness Committee invited faculty and staff to a Facebook page to share experiences, both triumphs and challenges. The Facebook page also posted resources, such as where to get food deliveries or how to talk to children about COVID-19. A faculty member began an informal All Staff and All Faculty email exchange, “The Daily (Uro) Flow”, in which individual staff or faculty members posted narratives and photos about how they and their families were living and coping during the pandemic. In all these initiatives and activities, emphasis was placed on viewing Michigan Medicine and the Department of Urology as a family that would support each other, get through the pandemic together and become strong as a result.

J.S. On a continuing basis, the hospital administration and our department have sent out frequent COVID-19 email newsletters to all staff members, including a summary of information from health authorities to support the dissemination of important information. Throughout the entire period, everyone has received full salaries, including those who were sent home without the possibility of continuing to work. Finally, all health-care workers have experienced huge support from society in general, with positive news coverage of the efforts of health workers and with examples including occasional free meals and snacks for staff on duty, free car rental for health-care workers in Copenhagen and free isolation stays at hotels for infected individuals.

What will be the long-term effects of COVID-19 in your institution?

J.J.A. The pandemic has expanded the use of telehealth owing to rapid and wide-spread changes in national and state-specific regulatory and licensing policies. Even beyond the pandemic, many more patients will have the option of following up with their doctors through video visits 2 . Ideally, this will keep healthier patients at home and open up capacity for patients with acute issues and complex medical needs. Hopefully, this will also give providers additional flexibility and more control over where and how they care for their patients.

This period will also have a lasting impact on our approach to medical education. We have seen how online sessions can reach a broad audience and that videos can be recorded and stored for review at a later time. In the future, medical schools might not need to continue growing in size if the majority of their content can be distributed electronically. Space can be shared and used for specific, hands-on tasks such as cadaver labs, simulations and selected group activities. Similarly, future medical students will be introduced to telehealth as a part of their curriculum. They will start performing video visits at the same time as learning how to do a physical examination in the clinic. Finally, this pandemic might even change the entire interview process; it is not impossible to imagine a system whereby applications are narrowed down through initial review, then virtual interviews and ending with a more selective pool of applicants interviewing in person. It will be interesting to see what long-term changes will come from COVID-19 that we cannot even foresee.

It is also clear that not everything can be shifted to a virtual medium. A different kind of fatigue comes from being connected to a computer or device for most of the day. I miss the sometimes brief but meaningful interactions that take place in the hospital, conference room and lecture halls. A quick hello, swapping of stories, a pat on the back from a colleague you haven’t seen in a while. These are all lost when people are bouncing online through innumerable Zoom sessions.

D.W. I expect that there will be more video visits in usual clinical care in the future, as long as insurance coverage continues. I also expect that Michigan Medicine will remain very much prepared to handle a possible fall spike in COVID-19 and that fast reorganization might occur again. It is not clear when in-person visits for usual care will return, given the lack of testing and treatment for COVID-19. Some patients are already voicing their preference for virtual care, citing both convenience and fear of becoming infected.

J.M.D. I am confident that the principal long-term effect will be the expanded use of telehealth 3 . We were using some telehealth before the COVID-19 pandemic, but when we had to postpone patients from in-person care, telehealth became essential. Even now, as patients are returning to our clinics, the benefits of telehealth — for doctors and for patients — remain.

I also expect us to restructure our clinical work. When we shut down all but the most urgent urological care, it gave us the opportunity to rebuild our clinical delivery system from the ground up, addressing longstanding barriers and reimagining how we can best provide high-quality, safe and efficient urological care to patients.

Finally, I expect, for better or worse, that there will be more centralized control of clinical operations in our institution. Centralized control was necessary during the pandemic to have a uniform and coordinated response. It will be hard to unwind some of that centralization. However, I think that individual clinics will need to regain some of their autonomy to help facilitate innovation and adapt to the unique needs of local patient populations.

G.S.P. There likely will be many long-term effects of COVID-19 at Michigan Medicine. Virtual care is one. Additionally, extended clinic hours (7 am–7 pm) and the addition of Saturday morning clinics and routine Saturday scheduled surgeries, staffed on a rotating basis, will also be likely incorporated on a long-term basis. The immediate financial impact has forced us to make some hard decisions regarding programmes and personnel. I suspect that in the future we will be much more cost conscious, which is not necessarily a bad thing. I also firmly believe that we as a department and institution will be better and stronger on the other side of COVID. This crisis has required us to take a hard look at what we do and how we do it and, importantly, made us prioritize and economize. Although hard to envision at the moment, I strongly feel that we will be in a better position 1 year from now than we were 1 year ago to take care of patients, make discoveries and educate the leaders of tomorrow.

C.F.S.J. Aside from constant hand hygiene, physical distance and mandatory SARS-CoV-2 tests for health-care personnel and patients, I foresee less physical interaction in general, including meetings, conferences and travel. Although virtual platforms can replace many of these activities, I fear that valuable aspects of direct interaction will disappear, leading to reduced sharing of information and experiences, as well as decreased input from peers. The lack of direct networking may even lead to a reduction in collaboration between institutions and a decrease in the development of new projects to benefit future patients. This has direct implications for programmes such as CopMich ( The Copenhagen Michigan Urological Collaboration ), which is an example of a collaboration built on direct interaction between Professor Jens Sønksen and Professor Dana A. Ohl (Department of Urology, University of Michigan), both clinical researchers sharing similar research interests. Without the established friendship, CopMich would not have been as successful as it has been, with more than 65 shared publications over 25 years. I am fortunate to be part of this friendship and I truly see the personal and scientific value in the relationships created 4 .

J.S. As a consequence of cancelling and postponing appointments for patients with urological conditions, there is a build-up of patients needing evaluation and treatment, which will require a substantial amount of time and effort to catch up on. This backlog will have implications for the workload of our staff and will limit the possibility for participating in educational and research-related activities, including participation in conferences. In a public-health system, we cannot expect additional financial resources for catching up, especially given the enormous amount of money used on governmental emergency relief plans. As a result, I fear we will lack money and opportunities to continue educational activities as we used to before the COVID-19 pandemic.

What lessons were learned during the response to COVID-19?

D.W. I have learned that I can do a lot of my work remotely. I have also learned that much of the ability to work effectively with others in this way is due to being able to rely on the comfort of pre-existing relationships. Doing new patient assessments or interacting with new research colleagues only virtually misses important human dimensions. I miss my colleagues and in-person patient care. As a health-care provider, I have also felt powerless, not useful, given the overwhelming need for specific expertise that I did not have. I offered to volunteer for blood donation and mental health services. I worried about providers on the front line of the COVID-19 work. I was reminded of how important it is to me to be of service.

J.J.A. I’ve had two main takeaways: first, the importance of your colleagues, co-workers and leaders in the workplace. In the face of an unprecedented pandemic and the anxiety evoked when models predicted that our hospital would be overrun within a matter of weeks, people were flexible and willing to adapt to work as part of a team — taking on tasks that would normally be split between two or three people, covering the on-call pager at night and on weekends that were previously scheduled for someone else. I feel very fortunate to be a part of this group. Residency itself is a shared experience like few others; add a pandemic to the mix and this is something that will connect us for the rest of our lives. Second, we have had the technology to connect with friends and family who live far away and have underused it for a long time. For the first time in years, I’ve had long phone and FaceTime conversations with people all around the country and world. Rather than texting or emailing, I’ve picked up my phone or used my laptop to talk, watch concerts together, and celebrate or mourn together.

G.S.P. I think there are several lessons we have learned from COVID-19 thus far. First, we are at our best when we work together. The collaborative spirit shown by our team during this time of crisis is inspiring. Second, we have seen the importance of communication. Frequent and clear communication from leadership about the status of the epidemic and our response to it, as well as the consequences of the crisis (such as financial issues), engendered better understanding of what was happening and built trust. Third, virtual care really does work! Our department had been using various methods of virtual care before the pandemic, but over the past 2 months our usage went up dramatically. For the most part, patients and providers have found virtual care convenient and I anticipate that it will play a major role in how we care for patients moving forward 1 .

J.M.D. I believe we will be realizing lessons from the COVID-19 pandemic for years to come. My most important lesson was a reminder about the importance of institutional culture. As I described above, our institution completely reorganized our clinical care operations within a few days. Everyone’s schedule changed, which, as you can imagine, was very disruptive. Thankfully, our urology department has a culture that values collaboration, teamwork and a shared sense of responsibility for our patients. These qualities shone as we responded to the daily changes in our lives.

Personally, I also learned several lessons about leadership. First, communication is a cornerstone of leadership, especially in a crisis. We used regular, clear and frank communication to reorganize our workforce and adapt to the changing epidemiology of the pandemic. Second, I learned the importance of being vulnerable and admitting when I do not know what is going to happen next. However, I also learned that it is valuable to pair that vulnerability with a clearly articulated belief in our ability to get through the pandemic together. Third, I was reminded about the benefits of feedback. It is tempting for leaders to make their own plans, assuming they know what is best. However, each time I asked for feedback on my plans, especially feedback from those on the front lines such as nurses, medical assistants and administrators, their responses made the plans better. There truly is wisdom in the crowd. Finally, I was reminded to give others the benefit of the doubt. In stressful times, there will inevitably be interpersonal conflict. Believing that everyone is trying their best given the circumstances was helpful as I navigated those conflicts.

C.F.S.J. I have learned to appreciate going to work as I quickly realized that working from home had several downsides and limitations and completely lacked the social aspect and daily input from colleagues. On the other hand, I learned that many activities, including meetings, do not necessarily have to be physical but can often be replaced by virtual meetings. However, this approach requires discipline and is a skill that needs to be learned 2 .

J.S. Many lessons can be learned from this unforeseeable situation. The most important thing is to have a plan for such situations. This was seemingly neglected, as Denmark has not been in a real emergency since World War 2. Furthermore, a clear structure for communication should be in place to avoid misinformation and misinterpretation.

Gadzinski, A. J. et al. Telemedicine and eConsults for hospitalized patients during COVID-19. Urology https://doi.org/10.1016/j.urology.2020.04.061 (2020).

Article   PubMed   PubMed Central   Google Scholar  

Gadzinski, A. J. & Ellimoottil, C. Telehealth in urology after the COVID-19 pandemic. Nat. Rev. Urol. https://doi.org/10.1038/s41585-020-0336-6 (2020).

Ellimoottil, C. What will urology look like in 2035? Nat. Rev. Urol. 16 , 635–636 (2019).

Article   Google Scholar  

[No authors listed] 15 years of urology at Nature : a celebration of collaboration. Nat. Rev. Urol . 16 , 631 (2019).

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Acknowledgements

This work was carried out on behalf of the CopMich Collaborative group. The authors from the University of Michigan and Herlev and Gentofte Hospital wish to acknowledge and thank all the nurses, physicians, nurse practitioners, physician assistants, medical assistants, students, schedulers, call centre agents, office staff and clinical staff who rose to the occasion and cared for our patients. More than any other time, responding to the COVID-19 pandemic was a team effort.

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Juan J. Andino, James M. Dupree, Ganesh S. Palapattu & Daniela Wittmann

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Andino, J.J., Dupree, J.M., Jensen, C.F.S. et al. COVID and CopMich: comparing and contrasting COVID-19 experiences in the USA and Scandinavia. Nat Rev Urol 17 , 493–498 (2020). https://doi.org/10.1038/s41585-020-0352-6

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Where public health stands 4 years after the COVID-19 pandemic began

Ayesha Rascoe

NPR's Ayesha Rascoe asks Dr. Nancy Messonnier, Jennifer Greene, and Raven Walters about the state of public health four years after COVID-19 became a national emergency.

(SOUNDBITE OF STATE OF THE UNION ADDRESS)

PRESIDENT JOE BIDEN: Four years ago....

AYESHA RASCOE, HOST:

President Biden reflected on COVID during his State of the Union.

BIDEN: ...The country was hit by the worst pandemic and the worst economic crisis in a century.

RASCOE: All this past week, we've been reflecting on it, as well.

(SOUNDBITE OF ARCHIVED RECORDING)

BIDEN: Remember the spikes in crime and the murder rate, raging virus that took more than 1 million American lives of loved ones, millions left behind, a mental health crisis of isolation and loneliness.

RASCOE: President Trump declared COVID a national emergency on March 13, 2020. That anniversary has come and gone, but COVID continues to affect us as we live alongside the disease. Today on the program, we look ahead at the future of the public health system that COVID pushed to the brink four years ago. We're joined now by Dr. Nancy Messonnier, formerly of the Centers for Disease Control and Prevention. Now she is the dean at the University of North Carolina Gillings School for Global Public Health. Thank you for being with us.

NANCY MESSONNIER: Thank you.

RASCOE: So Dr. Messonnier, you were one of the voices inside the CDC as COVID-19 began to spread that called attention to how disruptive the coronavirus could be. We want to play a clip of an interaction you had during your time in the CDC under the Trump administration.

MESSONIER: I had a conversation with my family over breakfast this morning, and I told my children that while I didn't think that they were at risk right now, we, as a family, need to be preparing for a significant disruption of our lives.

RASCOE: You know, following this comment, the stock market crashed, and then President Trump was reportedly furious about your comments. What comes to mind when you think back on that moment?

MESSONIER: Yeah. I, at this time of year, for the past several years, have reflected back on that moment and the data that I and my colleagues at CDC were looking at that drove us to really want to warn the country. But now that I look back, I realize it's hard for any of us to remember the fear and uncertainty and, frankly, chaos that was part of our lives at that time.

RASCOE: It was extremely chaotic. Do you think that was a product of the political system, the administration at the time, which was the Trump administration? Or do you think it was reflective of a greater problem with the public health system in the U.S.?

MESSONIER: I actually don't think any of us would have expected disruption of this scale and scope. While I do think that a stronger public health system would be helpful, frankly, the chaos was really a product of COVID-19.

RASCOE: In your view, though, what do you think could have been done better in those early days, especially from the public health perspective? So I guess maybe starting with, like, maybe communication, what do you think could have been done better?

MESSONIER: Yeah, it's really easy to sit here four years later and say, all of that could have been better 'cause the truth is, all of that certainly could have been better. But frankly, I also think that we should be proud about how many parts of our country stepped up. I mean, hospitals and doctors and nurses, the public health professionals that work at local and state governments - they were working full-tilt every day, 24/7, to really respond to the pandemic. And I admire their resilience and their willingness to throw themselves at those kind of emergencies.

RASCOE: Will the next once-in-a-century event - will it look like COVID-19?

MESSONIER: We are not great at making these predictions. And that's why when public health officials think about preparedness for the next emergency, we think about what we call all-hazards preparedness because if you too narrowly prepare around a specific scenario, you're not ready for something outside that. And that's why when you hear us talk about data systems or community-level activities or even racism, we're talking about things that have broad application not just for that next once-in-a-century pandemic but for the everyday emergencies that we're still dealing with.

RASCOE: All right. Now we also have two students on the line from UNC's Gillings School of Global Public Health, Jennifer Greene and Raven Walters. Welcome, and thank you for being here.

RAVEN WALTERS: Thank you.

JENNIFER GREENE: Thanks for having us.

RASCOE: So, Jennifer, I'll start with you. You lead the Appalachian District Health Department, which is a part of a big health system in the more rural parts of North Carolina. You're now pursuing a graduate degree in public health. Did the pandemic play a role in that decision?

GREENE: Yes, in some ways, it did. I - well, once I decided that I was going to stick it out. I had a few doubts there in the middle of COVID, but...

RASCOE: Well, can I ask you why you had doubts?

GREENE: Yeah, I had doubts because it just felt like this insurmountable mountain to climb. You know, we were working so hard. Think about testing access. Think about vaccines when they became available, all of the contact tracing - it was a heavy lift.

RASCOE: Raven, I want to turn to you now. You're wrapping up a master's in public health this spring. What drew you to this work?

WALTERS: Well, I started off a pre-med in undergrad, and I just wanted to keep conversations about preventative care, about maternal health. But then I got into the health equity concentration, and it opened an array of ideas and concepts for me that felt more broad but felt that I could also place it in any aspect of public health that I wanted to go in.

RASCOE: Since the pandemic, you know, people are really unhappy with the public health response during and after the pandemic, and that's from the perspective of people who felt like too much was done and from the people who feel like there was too little done. How do you communicate with a public that is increasingly skeptical of public health messaging?

MESSONIER: I think that we need to help the public understand more about what public health means. You know, there was a pandemic, but in fact, today, there are a variety of emergencies and urgencies that local health departments are working on and that schools of public health are studying. So I'm talking about opioids and the mental health emergency and climate change and the PFASes in our environment. Those are the kind of challenges that we are working on still every day.

RASCOE: We often hear a common criticism that public health does not have enough funding. In your view, what types of research or programs need more funding?

GREENE: Well, at the heart of it, we've got to invest in public health infrastructure. And what I mean by that is not buildings but people, staff development, data systems to help us modernize our antiquated and often very disjointed or siloed data systems. We saw CDC put out a public health infrastructure grant, and North Carolina has been using that at the state level and the local level, which is fantastic, and it's not enough. We need to do more.

WALTERS: But also, I'm working adolescent health right now, and my job is in mass incarceration and adolescent health. And we - there needs to be more conversations happening around mass incarceration as a public health topic.

RASCOE: Well, I wonder if you all are concerned about whether there is enough public trust to get people to buy in to prevention and containment efforts?

WALTERS: I think it's not necessarily a concern. I think the pandemic has taught us so much about public health and what can happen. Working to establish more trust, but also just making sure that language is there - that this is what public health is, and it's what it does.

MESSONIER: Maybe I'll add two more things that I don't think we've directly spoken about yet. One is that clearly, the pandemic made very apparent the inequities that exist in our health care systems and the impact of racism on outcomes. And I think that we have to be forthright at calling that out and addressing it.

The second issue that I would raise that we haven't spoken about is that this pandemic also really made clear how global the work of public health is. Countries are connected in a way that they haven't been before, and that is both for transmission of a virus through travel - but even the epidemic of misinformation can really cross country lines, and we really do need to think more about the global aspect of public health, including, for example, on data systems and surveillance.

RASCOE: So I have one extra thing I want to ask. It's this idea of an acceptable level of risk because it seems like there is a lot of concern from some people that public health officials have undersold the risk of COVID-19.

GREENE: We're in a different place than we were, which is great. We have a safe and effective vaccine, we have treatments available, and we aren't seeing the same volume of people who have severe illness, hospitalization and death. And that's a real accomplishment. And what I've noticed is people who are choosing on their own to make decisions about what events they visit or if they're going to wear a mask or how frequent they're going to wash their hands, and that's their choice. I've also heard people with more questions, and so that's why that communication and that relationship is important.

RASCOE: Raven, does hearing all of this - you know, the polarization, the lack of funding - does it give you any pause about the future of this sector?

WALTERS: No, it lights a fire, actually. I'm excited to do the work. I'm excited to fight for my communities. I'm excited to work with people to get what needs to be done, done.

RASCOE: Thank you so much for joining us. I really appreciate it.

WALTERS: Thank you.

GREENE: Thank you.

MESSONIER: Thank you.

RASCOE: That's Dr. Nancy Messonnier, dean of UMC Gillings School of Global Public Health, and students Jennifer Greene and Raven Walters.

(SOUNDBITE OF JOAN SHELLEY SONG, "OVER AND EVEN")

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Societal Impacts of Pandemics: Comparing COVID-19 With History to Focus Our Response

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The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

COVID-19 has disrupted everyday life worldwide and is the first disease event since the 1918 H1N1 Spanish influenza (flu) pandemic to demand an urgent global healthcare response. There has been much debate on whether the damage of COVID-19 is due predominantly to the pathogen itself or our response to it. We compare SARS-CoV-2 against three other major pandemics (1347 Black Death, 1520's new world smallpox outbreaks, and 1918 Spanish Flu pandemic) over the course of 700 years to unearth similarities and differences in pathogen, social and medical context, human response and behavior, and long-term social and economic impact that should be used to shape COVID-19 decision-making. We conclude that <100 years ago, pandemic disease events were still largely uncontrolled and unexplained. The extensive damage wreaked by historical pandemics on health, economy, and society was a function of pathogen characteristics and lack of public health resources. Though there remain many similarities in patterns of disease spread and response from 1300 onwards, the major risks posed by COVID-19 arise not from the pathogen, but from indirect effects of control measures on health and core societal activities. Our understanding of the epidemiology and effective treatment of this virus has rapidly improved and attention is shifting toward the identification of long-term control strategies that balance consideration of health in at risk populations, societal behavior, and economic impact. Policymakers should use lessons from previous pandemics to develop appropriate risk assessments and control plans for now-endemic COVID-19, and for future pandemics.

Introduction

COVID-19 has disrupted everyday life worldwide. It is the first disease event since the 1918–20 H1N1 Spanish influenza (flu) pandemic to demand an urgent global healthcare response, propagated by the speed and likelihood of potential transmission. An understanding of how much disruption is caused by the pathogen, and how much is caused by our reaction to its potential presence, is essential. We compare SARS-CoV-2 against three other pathogens known for the magnitude of their impact. Yersinia pestis , causative agent of the 1347 Black Death, is among the most destructive pathogens in human history. Variola major, cause of the 1520s smallpox outbreaks in the New World, exemplifies how disease impacts vary by population. Spanish flu is most similar to the current pathogen, yet major differences exist regarding scientific advancements and pre-existing immunity.

We compare across these four major disease events the rates of infection, likelihood of dying, and available diagnostics, therapeutics and vaccines ( Table 1 ). We examine the historical impact of these largely unchecked pathogens upon populations and economies. We discuss how culture and society's collective memory affect the response to pandemics and identify important lessons for decision-making as we adapt to a new normal.

Context and impacts of major pandemics.

Epidemiology

SARS-CoV-2 differs from Y. pestis , V. major and Spanish flu in terms of disease transmission and pathophysiology. Of these four, it is the least deadly, and poses the lowest risk to otherwise healthy people; however increasing evidence suggests significant long-term sequelae for a proportion of individuals who have symptoms. The Black Death had exceedingly high case fatality rates (CFRs), approaching 100% for septicemic and pneumonic plague and 50–60% for the bubonic form of the disease ( 8 ). Over a third of the European population died during the 1347 outbreak, with some regions experiencing up to 75% mortality ( 22 ). CFRs for smallpox amongst immunologically naïve native Americans in the 1520s were estimated at 50% ( 9 ), and many survivors were left disfigured or blinded. Smallpox (and other European diseases) drove an estimated 90% decrease in indigenous populations in the Americas from 1500 to 1600 ( 2 ). Spanish flu had a CFR estimated at 2–3% ( 23 ) and few known long-term effects, other than occasional extended convalescence and limited instances of neuropsychiatric disorders ( 24 ). Current COVID-19 CFR estimations range from 0.3 to 3.0%, with lower estimates more likely to be accurate ( 10 ). There are growing reports of secondary and long-term impacts from COVID-19, typically among hospitalized patients but also among less severe cases. These include poor cardiovascular functioning ( 25 ), wide-ranging neurological symptoms ( 26 ), chronic fatigue ( 27 ), and others, with some patients needing long-term convalescence. While it is too early to fully understand the long-term impacts of COVID-19, similar post-viral syndromes have also been observed among those infected with SARS ( 28 ).

It is unknown how many people were infected during the Black Death and 1520s smallpox outbreaks. An estimated 500 million people (1 in 3 worldwide) were infected with Spanish flu and 1–3% of the global population died from the disease ( 5 ). Thus far, 75.1 million people have been confirmed to have COVID-19 (~1 in 104), killing 0.02% of the global population ( 7 ).

Disease susceptibility and immunological naivety influence the outcome of pandemic disease events. Both plague and smallpox are highly infectious and affect people of all ages, though smallpox exhibits a significantly higher mortality rate amongst children compared to adults ( 9 ). Spanish flu had severe impacts amongst the otherwise healthy 15–40 age group while also affecting typically high-risk groups ( 23 ). COVID-19 is different; it has a low attack rate ( 29 ) and severe clinical disease occurs mainly in the old and those with pre-existing health conditions ( 11 ).

Y. pestis has evolved over centuries to evade and modulate innate and adaptive immune responses ( 30 ). In 1347, naïve Europeans would have had minimal immunological protection from the plague. Conversely, pre-existing herd immunity from years of smallpox circulation spared European colonizers the widespread mortality observed among naïve populations when smallpox was introduced to the New Word ( 9 ). While Spanish flu was likely a result of a novel variant, there is evidence of cross-protection in elderly populations who were exposed to historical flu outbreaks; this was also observed among survivors of later flu epidemics ( 23 ). It is unknown if exposure to commonly circulating coronaviruses provides protection against COVID-19, but reactivity against SARS-CoV-2 has been observed in T-cells from unexposed people ( 31 ).

While much of the modern world would be unrecognizable to our ancestors, certain dynamics of disease spread remain the same. Humans and domesticated animals historically lived at close quarters, and the risk of animal to human disease transmission was intuitively minimized thousands of years before a causal relationship was established ( 32 ). Communicable diseases spread more easily where there is poverty and/or high population density ( 33 , 34 ), as seen in Marseille where ~80% of the population perished in the Black Death ( 3 ). In India, Spanish flu mortality rates among members of the lowest social class were three times higher than that of other demographic groups ( 35 ). These risk factors remain relevant today: 73% of emerging infectious diseases in humans originate in animals ( 36 ), including COVID-19 ( 37 ). Large cities with international travel hubs, such as New York and London, were initially hit hard by COVID-19 and contributed to the unprecedented speed of global disease spread. Early understanding of the complex, multi-factorial role of socio-economic deprivation in COVID-19 spread, indicates that poverty remains a risk factor for poor outcome from infectious disease ( 38 ).

Mitigation and Economic Effects

Science and public health advances have accelerated over the last 100 years; we should be better equipped to respond to the current pandemic. The Black Death, New World smallpox outbreaks, and Spanish flu all occurred before the discovery of antibiotics and antivirals and the development of centralized public health surveillance; even the aetiological agent of each outbreak was unidentified at the time. Early forms of quarantine and isolation were employed during the Black Death, and sanitary cordons were enforced by armed guards ( 17 ). Outbreak spread was ultimately unmitigated for both the Black Death and New World smallpox, and no effective treatment protocols were available ( 9 , 39 ). The Native American custom of sleeping in close proximity to sick individuals would have spread smallpox even more efficiently ( 12 ). Mitigation tactics only slightly improved for Spanish flu, with sporadic use of non-pharmaceutical interventions such as track and trace, isolation, and social distancing ( 17 ). Late implementation, poor record-keeping, lack of a centralized global health body, and wartime priorities rendered these largely ineffectual. Public gathering spaces and schools were commonly shut down, but total lockdowns were not employed. Masks and disinfectants were used liberally, but ineffectively, and the only treatment was palliative care. Today, healthcare professionals can deploy antivirals, immune modulating drugs, antibiotics, oxygen, and ventilators to treat COVID-19 and related complications. At the time of writing (December 2020), the first doses of multiple vaccines for COVID-19 are being administered and surveillance systems have been established in many countries. Extensive lockdowns were enacted in most countries and travel restrictions, social distancing, and quarantine rules remain in place for the foreseeable future. Concern that healthcare capacity could be overwhelmed has stimulated rapid capacity building and shifting existing capacity away from day-to-day needs to help alleviate COVID-19. These modern tactics minimized harm from various infectious diseases but halted critical preventive activities, which may cause future chronic health burdens and global social and economic disruption surmounting that of COVID-19 alone ( 40 ). Countries such as Taiwan, which were able to locally eradicate the virus via swift but relatively short-lived enactment of nonpharmaceutical interventions, have suffered the least in terms of health, social and economic damage from COVID ( 41 ). Countries that have not been as successful in controlling spread of the virus (e.g., the United States - US) face long term health and economic damage from poorly coordinated and implemented control plans.

Historically, severity of disease has correlated with severity of economic outcomes. The Black Death caused a major labor shortage, providing unprecedented market power to common people and sparking a European peasant revolt ( 18 ). While trade and industry were temporarily damaged, the socio-economic structure of society was permanently redressed as wages increased. Skilled workers were increasingly mobile and spread innovative technology faster and further than before ( 18 ). Smallpox had less dramatic effects on the evolution of economic systems, but its unequal impacts on native groups paved the way for European conquest of the New World, through which mining of natural resources funded European empire-building ( 4 ). Smallpox often preceded the conquistadors, decimating populations and leading to starvation among survivors as their societal structure collapsed ( 9 ). Spanish flu closely followed World War I (WWI); both were particularly deadly for young to middle-aged men, which led to labor shortages and stalling of industry ( 20 ). These shortages were not as economically transformative as for the Black Death, perhaps as industry was less dependent upon mass labor, a smaller proportion of the overall workforce died, and more women and minors went into work outside the home ( 42 ). There is little evidence that Spanish flu caused major GDP or consumption declines or stock market volatility; major fluctuations had already occurred due to WWI ( 43 , 44 ). These outbreaks contrast with COVID-19, which poses minimal physical risk to most of the labor force but major economic risk from the unprecedented lockdowns and non-pharmaceutical interventions employed to contain the virus. Early transient labor shortages were driven by shifts in demand and movement restrictions ( 45 ). Now, mitigation measures drive record unemployment. COVID-19 related stock market volatility is unprecedented ( 43 ) and national GDPs have plummeted ( 46 ). It remains to be seen what detrimental effects will persist in the global economy, though experts predict wage contraction and widespread poverty, with profound effects on emerging markets and developing economies ( 21 ).

Collective Social Memory and Human Behavior

The Black Death, smallpox, and Spanish flu no longer pose an imminent threat to the global population, but they changed global population structure and economies and prompted scientific advances in disease eradication, antibiotics, vaccines, and surveillance systems. It is too early to understand the long-term effects of SARS-CoV-2 or whether we will eradicate this pathogen, but we should seek inspiration from the past for how to move forward in control.

Bubonic plague, smallpox, and Spanish flu have been controlled by herd immunity and scientific advancements, though plague and flu still circulate. Localized hotspots of infection may be our COVID-19 future as this disease becomes endemic. Over the past 80 years, significant resources were spent developing surveillance systems, vaccines, and programs to monitor and manage flu ( 17 ). For COVID-19, it is unlikely we will develop curative treatments, and, as asymptomatic cases make up an estimated 17.9–30.8% of infections, disease eradication is unlikely ( 47 ). The best approach may be that birthed from the Spanish flu: develop vaccines, efficient monitoring systems, and an understanding the epidemiology of the virus, when endemic. The “end goal” would be high-level vaccine coverage coupled with notifiable disease status. This will potentially take a long time: until this is achieved, how can COVID-19 be managed with maximal public cooperation coupled with maximizing economic activity?

Public responses to pandemic disease are largely unchanged since the Black Death. Disbelief of disease presence, misinformation, unclear public communication, disregard for governmental proclamations, and poor personal risk assessment were and are still common. Despite the rapid onset of bubonic plague, it often took weeks for plague infection to be recognized in a population. In 1630s Italy, physicians were “insulted on the streets” for warning people about the arrival of the bubonic plague ( 48 ). Today, media touting COVID-19 conspiracy theories are amplified by prominent voices ( 49 ). Conflicting information about ongoing disease has long been spread (purposely or not) by news media, sometimes at the behest of governmental leadership. In an example of wartime censorship, the Italian government forced a Milan newspaper to stop printing daily death tolls during the Spanish flu because it was too demoralizing ( 17 ). In the US, public health officials hid the extent of disease spread and downplayed the danger it posed ( 20 ). In attempts to keep morale up, leaders inadvertently eroded trust in public institutions.

Uncertainty and desperation can drive people to use of dubious modes of protection during disease outbreaks. Physicians in the 1300s recommended bloodletting and drinking wine to ward off the plague ( 15 ). During the Spanish flu people wore camphor bags and gargled saltwater, while early in the COVID-19 pandemic, many sought protection from zinc lozenges and off-label medications ( 50 ). In a parallel to modern times, official Anti-Mask Leagues were formed in the US during the Spanish flu, citing insufficient scientific evidence for mask use and violation of constitutional rights. These examples demonstrate that public response to pandemics is driven by personal assessment of risks as shaped by individual circumstances and belief systems, not necessarily government mandates. In an attempt to save their economy during COVID-19, the Swedish government did not impose lockdown. However, Sweden still experienced economic losses similar to their neighbors, as people spontaneously reduced mobility and economic activity ( 51 ), being unconvinced by the herd immunity strategy ( 52 ), and presumably having made a decision based their individual assessment of risk.

COVID-19 poses a more targeted threat to health than previous pandemics however we have more understanding of its etiology and epidemiology than would have been possible in previous centuries. Why then has our global response been so profound? Our collective understanding of pandemics, as shaped by literature and culture, may play some role. The historical fascination with plagues is evidenced by some of the earliest surviving English literature and is observed across art and entertainment. Geoffrey Chaucer's 1386 “Canterbury Tales” describes the effects of total social upheaval that arose from the Black Death and provides insight into a world shaped by the threat of plague. Albert Camus's 1947 “The Plague” accurately captures the now familiar atmosphere of lockdown, obsession with case counts, and feelings of powerlessness. More recent movies such as Outbreak and Contagion may be a modern individual's reference point for predicting the possibilities of horrific disease outbreaks (and indeed, sales of these increased markedly at the pandemic's outset) ( 53 ). All explore the effects of pandemics on fear as well as fear on pandemics ( 54 ). A specific challenge for the modern era comes via the immediacy of social media, where genuine and “fake” information are frequently presented with apparently equal credibility. The myriad collective experiences and cognitive biases innate to humanity are further challenges that scientists, policymakers, figureheads and communicators should be aware of in themselves and their audiences when formulating and communicating response plans ( 55 ).

In the era of COVID-19, scientific and medical advances have enabled us to identify and treat disease in a way that would have been unimaginable to previous generations. Therefore, the biggest danger we face are reactions that are disproportionate to the nature of risks from COVID-19, leading to challenges in core social activities of food production, provision of education, healthcare, and basic health needs. Indeed, one legacy of COVID-19 may be the corollary deaths that stem from disease control strategies ( 40 ). Major economic downturns are correlated with chronic disease and mental disorder-associated mortalities; already in 2020 we have observed short-term excess deaths not attributed to COVID-19 and reduced healthcare uptake. To minimize long-term harm to global health targets, decision-makers must balance the direct health risks from the virus against those from the socioeconomic effects of control strategies. The underpinning evidence and reasoning must be unified across government, medicine, and media, and presented to a mistrustful public with transparency. As seen in the past, illogical decision-making and poor leadership have the potential to multiply harm caused by disease. We must minimize the impact of this pandemic by accurately assessing and proportionately responding to the true threats of COVID-19 and its legacy.

Data Availability Statement

Author contributions.

The idea for this paper was initiated by JR and developed by GP, with input from KM and HC. GP wrote the first draft, with edits by JR, KM, and HC. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.