Editorials

Addressing the indirect health burden of covid-19

Zhihao Lei

BMJ 2025; 390 doi: https://doi.org/10.1136/bmj.r1268 (Published 02 July 2025)Cite this as: BMJ 2025;390:r1268

Consider collateral impacts when planning for future crises

The covid-19 pandemic’s impact extends far beyond the direct effects of infection and death, resulting in sharp increases in other causes of illness and death that demand attention. A new time-series analysis of the Global Burden of Disease data by Chen and colleagues (doi:10.1136/bmj-2024-083868) quantifies these shifts and identifies which conditions had excess burden during 2020-21.1 Their key finding is that many countries had greater than expected morbidity and mortality from non‐covid causes—a signal that health systems were strained in multiple ways. As such, policy makers must look past the virus itself and address collateral impacts. Health experts have noted that assessing health-system resilience now is “vital in helping policymakers plan for sustainable recovery” and to strengthen systems for future crises.2

The indirect health burdens have been profound. For example, a modelling study suggested that even modest service disruptions related to covid-19 in Africa could nearly double annual malaria deaths if routine programmes were interrupted.3 In practice, the findings suggest that malaria control campaigns could not simply be paused without consequences. Likewise, the pandemic has provoked a mental health crisis. The World Health Organization (WHO) reported a 25% global rise in anxiety and depression in 2020, reflecting the effects of lockdowns, fear, and isolation.4 Even well before the pandemic, mental illness was among the leading causes of disability worldwide; the new findings support the claims that covid-19 has worsened this burden. Other conditions, from diabetes to tuberculosis to maternal-child health, also suffered from disrupted care. Taken together, the evidence signals that post-pandemic health planning must explicitly “build in” catch-up programmes for diseases and such as malaria and for mental health services. The quantitative evidence from Chen and colleagues provides a roadmap for this by identifying which diseases and regions were most affected.1

A crucial lesson is that surveillance systems must be preserved and expanded. WHO’s guidance stresses that even as the acute crisis fades, countries should “maintain and strengthen surveillance” to give early warning of changing patterns and monitor health system burdens.5 In other words, health authorities need integrated data for both infectious and non-communicable conditions to rising trends of illness. As Clark and Gruending comment, without robust surveillance and preparedness “outbreaks place an enormous burden on health services”.6 This preparation calls for investments in unified health information systems, regular community surveys, and genomic tracking. In practice, health authorities should not shut down monitoring of malaria, HIV, or non-communicable disease while grappling with a pandemic, nor should data for mental health and substance use be neglected. Effective surveillance will allow timely interventions; for example, triggering extra mosquito net distributions or tele-mental health outreach, to blunt the indirect effects of future emergencies.

Building resilience and equity into health systems is equally vital. A multicountry review emphasised that recovery plans must “preserve functions and resources within and beyond the health system to maintain routine and acute care” even during shocks.2 WHO leadership likewise calls on governments to invest in core public health functions, to strengthen primary care and to involve communities in planning.7 Critically, they highlight the need to “address pre-existing inequities and the disproportionate impact of covid-19 on marginalized and vulnerable populations”.7The pandemic has shown that weak health systems and social divides amplify harm: as Tedros Ghebreyesus, the WHO’s Director-General observed, the brunt of the crisis has been borne by the most vulnerable, “when health is at risk, all other sectors are at risk”.7 Thus, policy measures should include expanded access to affordable care and social support for low income groups, migrants, and the elderly; measures that not only improve equity but strengthen society’s pandemic defences. Resilient countries also “activated whole-of-government approaches” and repurposed community health workers to sustain essential services for chronic diseases and mental wellness.2These examples illustrate that policies that are not strictly medical, such as paid sick leave, food assistance, and education continuity, are critical parts of a health protecting strategy.

In sum, the study by Chen and colleagues highlights how data can guide smarter recovery.1 The findings show policy makers where to target resources during the “rebuild” phase: immunisation and infectious disease programmes delayed by covid, mental health outreach to youth and frontline workers, and screening and treatment for chronic conditions deferred in lockdown. In each case, the cost of inaction is documented excess burden. By integrating these insights into postpandemic plans, countries can improve resilience. Concrete steps include: allocating budgets for essential services in emergencies, reinforcing primary health care, expanding disease surveillance networks, and prioritising universal health coverage with a focus on those left behind. Such actions are aligned with the WHO’s recommendations and the broader call to “build back better”, which aims that future health crises disrupt lives less and afflict populations more evenly.67 Ultimately, recognising and planning for the pandemic’s indirect toll will save lives and leave health systems stronger and fairer for future public health emergencies.