In March 2020, the pandemic closed in like a fog, ushering in a strange new vocabulary, alarming statistics and the fear of illness and death. In the days before the first national lockdown was ordered, the government’s chief scientific adviser suggested that a “good outcome” would be keeping UK deaths below 20,000, a number that sounded improbably awful at the time, but which has been dwarfed by the 233,791 deaths recorded as of December 2023. The direct effects of the Covid-19 virus have been profound and continue to be felt, including by those with long Covid. But four years on, the UK is also reeling from the broader health impacts of the pandemic. Babies and children appear to have suffered developmental setbacks due to lengthy periods of isolation. Access to healthcare continues to be affected. Older people, who needed protecting most from Covid, were also uniquely vulnerable to the effects of physical inactivity. For some individuals, the pandemic prompted a rethink of priorities and provided new opportunities that paved the way for a healthier life. But as a nation, it delivered a body blow, from which experts say recovery will not be easy or automatic. Babies and preschool children Babies born in 2020 emerged into a different world from those born before or afterwards. Even after the newborns left socially distanced hospital wards, grandparents and friends were kept at arm’s length (or farther), play groups and playgrounds were shut and interactions with other children were limited. “Some of the babies were born quite isolated, they didn’t see many people and most of the faces they saw would’ve been masked,” said Prof Monica Lakhanpaul, a researcher in child health at University College London and a consultant paediatrician. “They weren’t able to engage with other children as much, which affects emotional, physical and social development.” Official data shows national rates of child development are now lower among two-year-olds than they were in 2018-19, before the pandemic, with more than 80,000 children born in 2020-21 failing to reach one or more of the key measures of progress for their age group. “We have seen early years children who weren’t physically moving as much. We’re seeing children with speech delay because there was less human interaction,” Lakhanpaul said. “The caveat is that those most affected are those who we were already concerned about.” This is reflected in widening disparities between local authorities, with nearly 95% of children in Wokingham, Berkshire, meeting developmental targets compared with just 44% of those in Brent, north London. With many health visitor checkups done remotely, or postponed, fewer developmental delays were spotted. “Developmental milestones are like building blocks. You need the bricks at the bottom to get to the next stage,” said Lakhanpaul. “If everything is delayed, you can’t integrate with society and do all the things you’re meant to do with other children of that age.” A central purpose of measuring milestones is to prevent, or limit, this onward cascade by targeting interventions effectively. Prof Adam Finn, a paediatric researcher at the University of Bristol, makes a comparison with growth delays during a lengthy childhood illness. “Once they’re better, if you give them the food they need, they don’t just start growing again, they catch up and then they go back to normal,” he said. The same is true for some other aspects of development, he said, “but you have to do stuff to fix it; it won’t just happen by itself”. The concern is that those interventions are not happening – or not for everyone. “Schools are already working at capacity,” he said. “The ones that most need it are the least well resourced. The wealthy schools and the wealthy people have already got that and spare.” In February 2021, at the most intensive phase of the vaccine programme, Sir Simon Stevens, the then head of NHS England, said the country was facing a “dual epidemic” of coronavirus and disinformation, which needed to be fought with “equal vigour”. Some have blamed a lingering “vaccine hesitancy” for the declining uptake of childhood vaccines that is now threatening a resurgence of measles, polio and whooping cough (pertussis) in the UK. However, Finn, who is also a member of the government’s Joint Committee on Vaccination and Immunisation (JCVI), argues the pandemic has merely exacerbated an ongoing decline, mostly driven by poverty, insecure housing and overstretched NHS services. “There’s been a steady downward trend in coverage that was already going on before Covid and which has continued to go on since,” he said. “It’s not just down to anti-vaccine, mad internet stuff.” “The real problem we’ve got is around delivery,” he said. “The truth is that vaccination enjoys majority support that politicians can only dream of – surveys show 95% support. There’s not a big problem with people who don’t like vaccines.” With sufficient vaccine coverage, herd immunity protects everyone. But some areas, notably central London and the West Midlands, have slipped well below the critical threshold with potentially alarming health consequences that a national vaccine catchup campaign is now racing to avert. Without improved uptake of the measles, mumps and rubella (MMR) vaccine, London could be heading for a measles outbreak of between 40,000 and 160,0000 cases, which would lead to dozens of deaths and thousands of people being hospitalised, the UK Health Security Agency has estimated. A steep rise in cases of whooping cough – 553 were confirmed in England in January, compared with 858 for the whole of 2023 – is also prompting concern. “We’re seeing diseases that really haven’t been around since the later half of the last century,” Finn said. “We’re now two generations on – nobody remembers them. There’s this false impression that these illnesses don’t need to be worried about.” Primary school-age children With schools closed, sports clubs cancelled and playgrounds cordoned off, physical activity among primary school-age children plummeted during the first lockdown. Cooped up at home, many children were also eating more – and more unhealthily. Obesity rates increased steeply, by 45% in four- to-five-year-olds and by 21% in 10- to 11-year-olds during the first year of lockdowns. After the pandemic, obesity levels in the younger, reception-age children roughly returned to expected (still high) levels, but the proportion of children leaving primary school overweight, with obesity or severe obesity is now at a much higher level than before the pandemic. Almost one in four children aged 10 and 11 in England are living with obesity, according to a recent analysis of more than 1 million children. “Younger children went back to buzzing around and having broadly similar quality diet,” said Prof Keith Godfrey, of the University of Southampton and a co-author of the research. “But in the children leaving primary those poor health behaviours seem to have become embedded and there were persistent widening of disparities of advantaged and disadvantaged areas.” The soaring cost of healthy food is likely to have compounded the problem, with children living in poorer areas twice as likely to be obese than those living in wealthier neighbourhoods. Without active interventions, the majority of teenagers who are overweight or living with obesity remain on this trajectory into adulthood, meaning that an additional 56,000 children are facing a heightened risk of type 2 diabetes, cancer and other serious illnesses. “It’s among the biggest impacts of the pandemic,” Godfrey said. “Obesity affects a child’s ability to learn and consequently their economic opportunities. It affects their mental health. It affects their physical health, including asthma, susceptibility to diabetes, heart disease, osteoarthritis and a whole range of downstream health consequences. That is the sad and harsh reality.” Teenagers and young people Teenage years are generally defined by friendships, school, hobbies and a growing sense of independence. The pandemic swept much of this away. “There’s normally a process: you’re looked after by your parents, you’re observed by your parents and then you become independent,” said Lakhanpaul. “We’re seeing children who are more anxious about doing those normal risk-taking behaviours.” Multiple studies show a population-level deterioration in young people’s mental health, with higher levels of anxiety and depression, and there has been an unprecedented increase in non-attendance at school, with 28% of mainstream secondary school pupils classed as persistently absent (missing at least 10% of school days) in the last academic year. It would be wrong, though, to assume the mental health challenges faced by teenagers were freshly seeded by the pandemic. “It was amplifying and accelerating trends that were already evident,” said Prof Craig Morgan, a professor of social epidemiology at King’s College London. “And it was the people who were already the most disadvantaged who suffered most.” Prof Willem Kuyken, whose research found a rise in depression, and social, emotional and behavioural difficulties over the course of the pandemic, also identified factors that buffered young people against the toll of the pandemic, including a secure home environment and close friendships. Young people less likely to be shielded included those living in households affected by job loss, where parents were key workers, in overcrowded accommodation or with caring responsibilities for younger children. “If school is your safe place, the pandemic was awful,” he said. In south London, Morgan’s team asked dozens of teenagers to keep written or audio diaries of their experiences during the first year of the pandemic. “What really came through was a real concern about exams and academic progress,” he said. “As the pandemic wore on, things got worse.” One teenager said school had become a “prison of learning”, with all the fun stripped away, while others complained of unrelenting workloads and pressure. Limited internet and computer access meant some children were acutely disadvantaged. “There were parallel concerns about climate change and all of this crystallised into entrenched distress,” said Morgan. Recent figures from the Resolution Foundation showed a doubling in the number of 18- to 24-year-olds who were “economically inactive” due to health issues, including mental health, prompting a Daily Mail front page describing “Generation sicknote”. More sympathetic coverage of the “mental health crisis” in young people tends to focus on undeniably overstretched mental health services. But Morgan questions whether this points to the correct primary policy prescription. “The fact that we now frame everything in terms of mental health means that all of these problems are subsumed under this single heading without any granularity,” he said. “It places the problem within the child and that serves to obscure some of these wider, contextual factors. The narrative around mental health is blinding us a bit to what is driving it.” At worst, this can lead to well-meaning interventions that are ineffective or can even serve to widen inequalities. A recent trial by Kuyken and others, for instance, found that mindfulness training in schools did not improve mental health – although there was some indication of benefits for pupils who were well at the outset and who were most engaged. “If you’re not having breakfast and your parents are struggling, I’m not sure how being ‘in the moment’ is going to touch that in terms of how you feel,” Morgan said. “We need public health initiatives, such as free school meals and free internet access. You’re never going to address a population-level public health problem by providing more counsellors.” Adults Navigating healthcare systems tends to fall to adults in mid-life: for themselves, children and parents. The strain the pandemic placed on the NHS has made securing appointments, being referred to specialists, obtaining diagnoses and treatments an increasingly competitive pursuit that is driving inequalities. Some areas of medicine have been affected more than most. Gynaecology waiting lists increased by 60% between 2020 and 2022 – a bigger proportion than any other area of medicine. Despite the government launching a widely welcomed women’s health strategy, there is concern that diagnostic waiting times for conditions such as endometriosis have deteriorated, with women in England now waiting an estimated nine years. Private healthcare has become a “new normal” for sections of society, creating a “two-tier” system for dental care, cataract removal, hip replacements, cancer diagnosis and gynaecology scans. But even within the NHS, different people receive different care. Long Covid, which has a higher prevalence in people aged between 35 and 69, is a case in point. When the condition first emerged, doctors sometimes noted a stereotype among patients attending new specialist clinics: many were high achievers, thriving professionals, the kind of people who ran marathons at the weekend. Some speculated these people were pushing themselves too hard after being unwell. Prof Claire Steves, an ageing and health researcher at King’s College London and a consultant geriatrician, has an alternative explanation. “In order to get through the system, you need to have loads of social advantages,” she said. “You probably know about healthcare and are able to bash through the barriers.” Studies have found that white, middle-class, more educated people are over-represented at long Covid clinics, but population-based surveys, where people are sampled randomly, show you are more likely to get long Covid if you live in a deprived area, and do not show a bias based on ethnicity. “There are really stark differences in access to care,” said Steves. In 2020 and 2021, “How was your lockdown?” became a familiar question: some took up new hobbies or got a dog; for others it was universally bleak. “We talk about ‘the pandemic’ but there were many different situations that people experienced,” said Dr Darío Moreno-Agostino, who researches population mental health at King’s College London. His team has used longitudinal data, including cohorts born in 1970, 1958 and 1946, to look at how these people who have been tracked for decades fared. With the pandemic, all three generations reached or surpassed the worst mental health levels ever experienced in up to 40 years. “One of the things that we keep finding is that women were disproportionately impacted,” he said. “There are quite stark differences by gender.” For the past 20 years, women in the 1970 British Cohort Study had reported higher life satisfaction, on average, than men, but during the pandemic this difference disappeared. “It’s talking about a historical advantage on life satisfaction being lost,” said Moreno-Agostino. Older people Within weeks of the earliest reports emerging from China, it was clear that Covid posed a particular danger to older people. In the UK, a “stay at home” order was issued to people over 70 and pregnant women a week before the first national lockdown. Compliance in older age groups was high, and as stories emerged of care homes being ravaged by the virus, some were left afraid of leaving the house even to exercise. “We were quite shocked at how much people’s physical activity changed over the pandemic, especially in older people,” said Steves. The profoundly negative health impacts of inactivity is sometimes overlooked, with evidence that it can be at least equal to the effects of smoking, drinking and obesity. Spending a lot of time sitting increases the risk of heart disease, diabetes and some cancers. “It’s not the case that because you’re older you can’t benefit from exercise – if anything you can probably benefit more,” said Steves. Data analysed by Steves from TwinsUK, a registry of 14,000 identical and non-identical twins, showed a substantial decrease in physical activity among older adults, and those who had the lowest strength to begin with were most affected. Blood pressure rates, obesity rates and alcohol consumption all increased, too. This is worrying because when it comes to physical activity there is a threshold effect. A marathon runner in their 70s who reduces their activity for a few months will still be fully functional. But someone on the brink of being unable to live independently could tip into a more profound decline. Steves and colleagues are actively studying the extent to which activity levels have bounced back – and which factors predict recovery. But she is concerned that a “wave of frailty” will be seen in the older population. Across all age groups, the pandemic appears to have chipped away at health and the NHS treatment that people receive. The challenge of reversing these trends can appear overwhelming and insurmountable, but recognising the scale of a problem can also, in time, galvanise a proportionate response. “There are parallels with the Industrial Revolution, which was really bad for health inequalities,” said Steves. “But that was followed by a period of philanthropy, government leadership and infrastructure changes. The pandemic does have a legacy that’s important for health. So we need to also think about how this could be a major opportunity.”