The double burden of COVID-19

When the nature and scale of a problem is new, it cannot be approached by standardised methods because it represents a unique challenge and because all possible solutions may lead to unknown negative consequences [1]. This description fits the challenges faced by COVID-19 well. Because the nature and scale of COVID-19 are new, there are no proven solutions to tackle the pandemic. This is why countries have implemented different strategies, and this is why these strategies may even change from one day to the next. The Nordic countries are not an exception in this respect, and the varying strategies implemented in these countries have led to large variations in the early impact of COVID-19 infections and mortality [2]. The Scandinavian Journal of Public Health will publish a series of special issues dedicated to the shortand long-term social, economic and healthrelated consequences of COVID-19 in the Nordic countries and beyond. In this first special issue, we present a series of commentaries, empirical articles and one study design article that together highlights not only the uncertainty and complexity of the pandemic, but also some of the opportunities for research and guidance in terms of suggestions for policies. The issue also includes a memorial to honour a fellow research colleague who unexpectedly died at a young age during the worst of the pandemic. Although many of the challenges faced by COVID19 are new to modern society, the world has faced pandemics before. Above all, they have taught us that pandemics do not hit countries, societies and individuals equally. In fact, they are experienced unequally, with higher rates of infection and shortand long-term morbidity and mortality among the most disadvantaged groups – particularly in more socially unequal countries [3]. Emerging evidence from a variety of countries suggests that these inequalities are being mirrored today in the COVID-19 pandemic [4]. Both then and now, these inequalities have emerged through the syndemic nature of COVID-19 as it interacts with existing social inequalities in chronic disease and the social determinants of health [3]. This happens because people living in poor areas have a higher proportion of almost all known underlying risk factors (such as high blood pressure, diabetes, asthma, chronic obstructive pulmonary disease, heart disease, liver disease, cancer, obesity and smoking) that increase the severity and mortality of COVID-19. Ethnic minorities [5], nursing home residents [5], the elderly [5,6], refugees [7], the homeless, migrants, sex workers and inmates in prisons are just some examples of marginalised groups that have a higher proportion of chronic disease than the rest of the population. Social inequalities in underlying chronic diseases come as a result of social inequalities in access to necessary benefits such as education, good working conditions, housing, food, clean water and healthcare. When the pandemic hits poor countries and poor areas within countries, they are hit harder because they are already over-represented with chronic conditions. This also happens because one of the most effective measures to reduce the spread of the coronavirus is social distancing. This is more challenging for people living in crowded housing conditions with little opportunity for selfisolation, which is often the case in poor areas, and for people who work in the service and health sector with greater contact with other citizens and less job flexibility. This happens as well due to language challenges for some citizens from an ethnic minority background who do not have the same opportunities to understand the changing recommendations from the health authorities and thus apply appropriate The double burden of COVID-19