Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 1 | 15 ORIGINAL RESEARCH How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic Adhitya Satyamoorthy1, Helmut Brand1,2, Robin van Kessel1,3 1 Department of International Health, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; 2 Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karna- taka, India; 3 Maastricht Working on Europe, Studio Europa, Maastricht University, Maastricht, The Nether- lands. Corresponding author: Prof. Dr. Helmut Brand; Address: Department of International Health, Maastricht University, Duboisdomein 30, 6229 GT Maastricht, The Netherlands; Email: helmut.brand@maastrichtuniversity.nl Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 2 | 15 Abstract Aims: The article aims to analyze what can be learned from the last Financial Crisis from 2008 on to minimize the negative health effects in the European Union due to the Economic recession caused by the Covid-19 Pandemic. Methods: Systematic literature reviews were conducted to analyze the interventions taken to com- bat the last Financial Crisis and their consequences on health. Parallel to this, a qualitative docu- ment analysis of the ongoing discussion about the measures taken or to be taken in the Covid-19 Pandemic to fight the current economic recession was conducted using institutional websites and international media. Results: The main methods taken to combat the Financial Crisis from 2008 were, bailing out banks, austerity measures, and the European Stability Mechanism. There is evidence that the Fi- nancial crisis had negative effects on the European Health Systems in general. Austerity measures in some countries, led to an increase in psychological disorders. Overall mortality was not affected but the decrease of avoidable mortality slowed down. Various economic interventions such as bailing out essential industries e.g., the Aviation sector, cash injections, tax relief, short-work sal- ary compensation, modified ESM, and the Pandemic Emergency Purchase Program (PEPP) were taken during the Covid-19 Pandemic to help stabilize the economy. Conclusion: The current recession is not caused by internal failures of the financial system as it was in the financial Crisis of 2008, but by an outside event - the Covid-19 pandemic. Measures were taken by the governments and the European Union to avoid an economic crisis, and by these, the negative health effects were created during the Financial Crisis in 2008, but the lockdown phase seems to lead to similar negative health effects regarding psychological disorders and delay of planned screening and treatment. Keywords: austerity, COVID-19, economic measures, financial crisis, health, pandemic. Conflict of interest: None declared. Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 3 | 15 Introduction In December 2019 an outbreak of the virus, Severe Acute Respiratory Syndrome Corona- virus 2 (SARS-CoV-2), occurred in Wuhan, China, which developed into the COVID-19 pandemic (1). The virus that caused COVID- 19 spreads mainly when an infected person is in close contact with another person or small droplets and aerosols is in the air (1). At the beginning of 2020, 23 million people were infected worldwide, out of which, 800,961 people died (2). To combat the pandemic in the absence of a vaccine several non-pharma- ceutical measures such as lockdowns were adapted by infected countries. This was to prevent the spread of the disease and not overload the health system with patients. A side-effect of these measures is that they had and still have a serious influence on the econ- omies of infected countries that finally led to a worldwide recession (3). The Gross Do- mestic Product (GDP) shrank by 12.1 % in the European Union at end of July 2020 (4). By this, the Covid-19 Pandemic has the high- est negative effect on the economy of all in- fectious disease outbreaks in the last decades (5). Next to the direct burden of ill-health due to infected people, there is the risk of an indi- rect burden of ill-health caused by the measures taken to combat the economic re- cession as we learned from studies that looked into the effect of economic decline on health (6). The European Union and its Mem- ber States had to choose interventions to min- imize these negative health effects. Figure 1, originally presented by Douglas and col- leagues (7), visualizes the interdependencies between the different measures taken to fight the pandemic and illustrates the pathway of economic consequences leading to indirectly attributable morbidity and mortality. The last financial crisis started in August 2007 in the United States. The excessive risk taken by banks along with the bursting of the United States housing bubble caused the financial downturn in the United States (8). Real estate was hit the most damaging various financial institutions globally. This was then followed by a Global Financial Crisis in September 2008 that later developed into the Great Re- cession in 2009-2010. The Financial crisis of 2008 in Europe initially affected Portugal, Ireland, Italy, Greece, and Spain. This led to a loss of confidence in European businesses and economies. Unsustainable fiscal policies and overleveraged banks led to a Sovereign Debt Crisis in the Euro area in 2010 (8). The research objective of this article is to analyze if the measures taken to combat the last Fi- nancial Crisis should be applied this time too. By comparing the current economic reces- sion with the Financial Crisis of 2008 and the economic measures taken then, we can theo- rize if the measures would work during the economic crisis caused by the COVID-19 pandemic. Methods Ethical Consideration This literature review was based on published reports and was therefore exempted from eth- ical approval. A systematic literature review was conducted on the measures taken to com- bat the financial crisis of 2008 and, on the health effects the crisis had, using databases PubMed, Web of Science, and EconPapers from the years 2009 to 2020 using a combi- nation of Boolean operators (AND/OR), Medical Subject Headings (Mesh) and pre- defined keywords. Peer-reviewed papers in English on measures taken to combat the fi- nancial crisis of 2008 and the health effects of the crisis were retrieved and independently evaluated for eligibility based on the title and abstract. Thereafter, full texts of eligible pa- pers were accessed according to the pre-de- fined inclusion and exclusion criteria. The Preferred Reporting Items for Systematic Re- views and Meta-Analyses (PRISMA) 2009 guidelines were followed (9). Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 4 | 15 Figure 1. Effects of Social Distancing Measures (7) Search Strategy and Data Collection For the review on the measure taken to com- bat the Financial Crisis in 2008 and health ef- fects caused by the crisis, keywords were “Fi- nancial Crisis 2008”, “Economic impact”, “Eurozone crisis”, “Measures”, “Austerity”, “Health Effects”, “behavioral effects”, and “Europe”. The time span of publications was from 2009 to June 2020. The Great American Recession 2007-2009, the measures taken during the financial crisis of 2008 in the United States of America, countries outside the European Union, and published articles in other languages apart from English were ex- cluded. Parallel to this, a qualitative docu- ment analysis regarding the content of the on- going discussion about the measures taken or to be taken in the Coronavirus Pandemic to fight the economic recession was conducted to watch out for evidence about indirectly at- tributable morbidity and mortality. Sources monitored were the institutional websites, e.g., of the European Commission (EC), the European Centre for Disease Prevention and Control (ECDC), the European Central Bank (ECB), the World Bank, the European Invest- ment Bank (EIB), the International Monetary Fund (IMF), the Organisation for Economic Co-operation and Development (OECD), and major International Consultant Companies and newspapers. For the review on how to combat the 2008 Financial Crisis and the health effects of the financial crisis of 2008, 668 articles could be identified via the data- bases searched, and 35 articles via additional sources. Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 5 | 15 After checking for relevance 36 articles were included. The qualitative document analysis of the institutional websites was included till the end of June 2020 and 13 results were used. Figure 2. Systematic literature review on economic measures taken during the financial crisis 2008 (9) Records identified through database searching (n =407) Sc re e n in g In cl u d e d E lig ib ili ty Id e n ti fi ca ti o n Additional records identified through other sources (n = 21) Records after duplicates removed (n =378) Records screened (n = 378) Records excluded (n =280) Full-text articles assessed for eligibility (n =98) Full-text articles excluded, with reasons (n =84) Studies included in synthesis (n = 14) Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 6 | 15 Results Measures taken to combat the Financial Crisis of 2008 The primary cause of the 2008 financial crisis in Europe was the bursting of a property bub- ble in the United States of America in 2007 (10). The crisis resulted from a structural problem of the Eurozone, and a combination of factors, which included the globalization of finance, easy credit system that encourage high-risk borrowing, lending practices, inter- national trade imbalances, a real estate bub- ble, unsustainable fiscal policy approaches related to government revenues, and ex- penses and approaches used by certain na- tions to bail out troubled banks and private bondholders (11). The first interventions were to prevent the collapse of the banking Figure 3. Systematic literature review on health effects of financial crisis of 2008 (9) Records identified through database searching (n =261) S cr e e n in g In cl u d e d E li g ib il it y Id e n ti fi ca ti o n Additional records identified through other sources (n =14) Records after duplicates removed (n =246 ) Records screened (n = 246 ) Records excluded (n =203) Full-text articles assessed for eligibility (n =43) Full-text articles excluded, with reasons (n =21) Studies included in synthesis (n =22) Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 7 | 15 sector and the second interventions tried to avoid a massive drop in demand (12). Mem- ber States made efforts to prevent mass un- employment and made sure workers would retain their relationship with the labor mar- ket, e.g., by implementing short-time work schemes. This was one of the main reason’s governments had to raise taxes and cut back social expenditure (13). Investments in jobs and government infrastructure, tax measures, and tax reliefs were implemented (12). Other measures such as lowering interest rates and buying government bonds were part of the monetary policies of the EU that would help to cope with the financial crisis (14). Be- tween October 2008 and May 2009, The Eu- ropean Central Bank (ECB) lowered its inter- est rate to maintain price stability in the Euro area. The enhanced credit system focused on commercial banks, as they were the main source of funding for businesses and house- holds in the Euro area interbank market (15). Public debt increased, national credit ratings fell and the cost of borrowing increased. This led governments in Europe to impose harsh austerity measures which would reduce pub- lic spending (13). During the crisis, unem- ployment increased rapidly in Europe. The European Central Bank (ECB), the European Investment Bank (EIB), and the International Monetary Fund (IMF) along with leaders of European member states placed a priority to reduce the deficit (16). The majority of the deficit reduction policies by European gov- ernments involved further budget cuts rather than tax increases (16). Health Effects of the financial Crisis of 2008 in Europe The 2008 Financial crisis in Europe not only had an economic impact but has also a short, medium, and long-term impact on the health systems and the health of individuals (16,17). Economic growth, democratization, and im- proved living conditions have contributed to better population health in most European countries, but health inequalities are still prevalent (18). These inequalities are mainly caused by daily living conditions, inequali- ties in available money, and resources which affect individuals during a financial crisis due to loss of employment. This leads to a change in lifestyle which may include smoking, alco- hol consumption, and nutrition intake (19,20). In times of an economic crisis, households will also limit their spending on health (21). The Financial crisis of 2008 caused, in some countries, severe psycholog- ical disorders which included depression, anxiety, and suicidal behavior (22). Over time suicides and psychological disorders in- creased by 7% because of unemployment, loss of income, and housing instability e.g. (in some southern European countries) (23). Countries such as Greece started to reduce their health care budget during the financial crisis in 2008. The tight restrictions of budg- ets on the health care system worsened the health system performance and also led to a slowdown in the reduction of avoidable mor- tality (24). Impact of the Covid-19 Pandemic on the Economy in Europe The Impact of Covid-19 Pandemic on the economy is severe (25). The manufacturing sector was affected due to lockdown measures as e.g., it depends on the physical presence of the workers. The travel and tour- ism sector experienced great difficulties as the movement of people was restricted. The closing of public places led to a supply chain disruption. Educational institutions had to shift to online education. The entertainment industry experienced a total standstill as gath- erings were forbidden. All of this resulted in the loss of jobs and income and also reduced demand and supply (25-27). This influenced the consumers’ confidence as they hesitate to buy products in the face of possible job loss Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 8 | 15 or reduced income. In summary both, supply and demand were reduced in the Pandemic (3,28). Some of the currently discussed eco- nomic measures to solve the crises are al- ready implemented (25,29,30). They focus either on individuals by offering temporary cash for vulnerable households, expand short-time work schemes, and increasing re- sources for health care (27,31). For the indus- try, the reduction or delay of paying taxes for affected sectors is discussed (32). At the State level, Fiscal Consolidation is needed to ex- pand liquidity and availability of credit to firms (32,33). Regulations on reporting bank- ruptcy have been delayed. Regarding macro- economic policies, the expansion of liquidity to banks is discussed (30). Further, it should be ensured that monetary policy can respond to extreme market conditions (32). The Euro- pean Union (EU) agreed upon a recovery fund and a long-term budget that supports its citizens and business from the economic cri- sis caused by COVID -19. The European Un- ion’s long-term budget called the multiannual financial framework (MFF), of 1,100 Billion Euros for the year 2021 to 2027 can be con- sidered vital in the recovery of the economy (27). The EU has also sanctioned temporary funding of 750 Billion Euros called the Pan- demic Emergency Purchase Program (PEPP) (30,33). The PEPP program would help the Member States in supporting their citizens and businesses. This included compensation on employees’ wages, supporting small and medium-sized enterprises (SME), and sup- porting businesses with tax reliefs or delayed taxes (25,27,31). The effect of the measures is still unknown due to the recent implemen- tation. Some European Member State Gov- ernments have started to bail out national air- lines (34) as the aviation and the travel sector were one of the most affected sectors during the lockdown. But not all sectors were af- fected equally. The IT sector for example is expected to double its revenue in the second quarter compared to the first quarter in March 2020. Companies such as Apple and Google even saw an increase in their share price from the beginning of February to the first week of August by 8.26% and e-commerce compa- nies such as Amazon and eBay saw an in- crease in their share price by 29.64% from the first week of March to the first week of Au- gust (35). The increase in growth of online sales has helped the e-commerce industry be- cause consumer confidence has increased in online sales. This in return helped increase business and industry confidence. The Sup- ply chain for certain products from China had come to a standstill. As China today is seen as the workbench for Europe this had major implications for the availability of most goods. This was very eminent in the discus- sion about missing PPE due to the import from China. Therefore, many countries are encouraging companies to relocate produc- tion in their own country and have committed to support this with dedicated investments into manufacturing through programs such as the ESCALAR (35). Health effects of Economic Recession 2020 in Europe The mortality impact of COVID-19 has been of major concern in Europe and the rest of the world. As of the beginning of August 2020, there were a total of 216,478 deaths (32). The impact of lockdowns adopted by the Member States can have unintended health effects (36). Lack of social contact can result in men- tal health issues, limiting physical activity can result in obesity and a rise in domestic vi- olence. The current financial situation can cause uncertainty and stress that would result in a negative health effect in the short term (37). Due to lockdown, people are not travel- ing and by this, the number of traffic acci- dents is supposed to go down (38,39). There have been concerns that the measures taken to mitigate the COVID-19 Pandemic Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 9 | 15 could increase the number of deaths from other diseases. One of the major issues is that people hesitate to go for treatment as they fear they would be infected by the COVID- 19 virus. Or, that they do not like to burden the healthcare system when it is already un- der pressure due to the pandemic (37,40). Hospitals are delaying the treatment of non- COVID-19 patients as they are trying to pri- oritize the cases related to the pandemic (40). Therefore, apart from the official COVID-19 deaths, there are additional deaths that may be directly or indirectly related to it. Due to the lockdown and social distancing measures about 2.1 million people missed out on can- cer screening. There have also been up to 290,000 people with suspected symptoms that have not been referred to any hospital or any treatments (37). This is because during the lockdown health systems focused on pa- tients with COVID-19 and other services like cancer screening were postponed. Due to this, there might be around 230,000 cases of cancer gone undetected. Cancer requires prompt diagnosis and treatment; hospitals can’t do so because they are over capacitated by COVID-19 patients. This would increase the number of cancer cases over the long term (41). Discussion The rapid spread of COVID-19 prompted many governments to impose serious and strict lockdown measures. These measures have made many businesses shut down tem- porarily, led to restrictions on free movement and travel, financial market going turmoil, and decreased consumer confidence (42). The measures taken in Europe to help and boost the economy are relatively large com- pared to those measures taken during the Fi- nancial Crisis in 2008. The magnitude of the impact of these measures on the growth of GDP is still unknown due to their recent im- plantation. Data on the economic effect of the pandemic are not yet available or accessible since some statistics are produced on a quarterly or yearly basis. As there are different reasons for the origin of the crisis, some macro-economic effects might be different so the actions to be taken might not be the same. Table 1 compares the reasons for the two cri- ses, the effects on the economy, the measures taken, and their effects. Table 1. Comparison of the Financial Crisis of 2008 with the Economic Recession 2020 Financial Crisis 2008 Economic Recession 2020 Reason for crises From inside the Financial System (Bursting of a Property Bubble) From Outside of the Financial Sys- tem (SARS-CoV-2) Effects on the Economy Global Recession, Credit Crunch. Global Recession, No demand and no supply. Measures taken Bailing out Banks, Austerity Measures, European Stability Mechanism (ESM) introduced. Bailing out essential industries e.g. the Aviation Sector, Cash injections, Tax relief, Short-work salary compensation, Modified ESM, Pandemic Emergency Purchase Pro- gram (PEPP). Effect of measures taken The economy recovered over time. Short-term Economic recovery, Long-term Economic Recovery is unclear. Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 10 | 15 The reasons for the shock and impact on the world economy are different in 2020 when compared to the Financial Crisis in 2008. In 2008, the problem was a banking crisis which was the result of too much “bad debt”. Now it is the supply chain shock having a knock- out effect on the market (43). Various leading economists have urged governments to bring out measures to fight the economic downfall. They suggest reducing personal and corpo- rate bankruptcies, ensure people keep spend- ing even though they are not working, in- crease public investment, increase healthcare spending, and using an unconventional pol- icy called the helicopter money where the governments print new money and distribute it among the public during a recession (44). Stock markets fell about 33% from March compared with 55% during the 2008 Finan- cial Crisis. But this comparison is for the short period of the economic crisis in 2020 with a much longer period of the Financial Crisis of 2008. The shock on the economy in 2020 is different since the lockdown has se- verely hampered every sector from the begin- ning when compared to the Financial Crisis of 2008 where mostly the banks were af- fected first. This shows that the economic outcome of the COVID-19 Pandemic seems worse when compared to the Financial Crisis in 2008 in a short term. One can compare the fall of the stock markets to the post-collapse of Lehman Brothers which stands at 33% and 19% respectively. If income is held up for even four months, it will drive firms into in- solvency which will result in unemployment, loss of income, reduced consumer confi- dence. Consumer confidence slumped to a level that has not been seen since the Finan- cial Crisis in 2008. This shows that the pan- demic has a serious toll financially and eco- nomically (45). The consumer confidence in- dicator fell to minus -15.6 points during the COVID-19 economic crisis compared to - 11.2 points during the Financial Crisis in 2008 (46,47). Unemployment, loss of in- come, lack of supply or production which lead to increased prices have all severely de- creased consumer confidence. This also shows that most of the people are unsure and pessimistic that the COVID-19 Pandemic will have a lasting impact on the economy, and this would be a lengthy recession (43). Financial markets and the Economy already bounced back, but the question is if this will be in the form of a sharp “V”, a prolonged “U” or even an up and down in the form of a “W” (48). In general, it is hard to attribute ad- verse health effects to a single cause in a sit- uation of economic downturn. The available literature on the health conse- quences of the Financial Crisis 2008 is (sur- prisingly) still scarce and prone to bias from an epidemiological viewpoint. The results for the Health Effects of the Fi- nancial Crisis in 2008 and assumed Health Effects of the Economic Recession in 2020 are summarized in Table 2. The hypothetic health effects of the current Pandemic are marked by “(?)” Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 11 | 15 Table 2. Health Effects of the Financial Crisis in 2008 compared to observed and hypothetic health effects of the Economic Recession in 2020. Hypothetic effects marked by “(?)” Financial Crisis 2008 Economic Recession 2020 short Health Systems experienced financial stress, Increase of HIV infections (due to the de- crease of preventive measures), Less Road traffic accidents. COVID related mortality increased, Increase of alcohol consumption and violence in families, Increase in depression and anxiety disorders, Reduced physical activity during the lockdown, Less traffic and work-related (?) accidents, Less Cardio-vascular diseases due to better air quality (?). medium Access to and Coverage of care decreased in some countries, Unmet need in health increased in countries with high co-payment, Increase of Depression, Suicide, and other psychological disorders, Increase in Homicide and alcohol-related death. Increase of Non-COVID related mortality, Increase of Cardio-vascular mortality (Stroke, Myocardial infarction) due to delay in treat- ment because of Corona fear and unemploy- ment (?), Psychological stress for younger people be- cause of delay in schooling, graduation, and first-time employment (?). long Increase of Health Inequalities, Lower self-rated health in unemployed, No effect on overall mortality, Decrease of household spending on health, Decrease of avoidable mortality slowed down, No change in Birth Weight, Fetal Death, or Infant Mortality, Small but significant increase in overall Morbidity. More Cancer cases due to low uptake of screening and delayed treatment (?), No increase in overall mortality (?). This take-away summary shows, in general, no surprises in the expected events. Mental disorders occur when societies are under stress. The consequences of this are higher rates of alcoholism and violence in families. These “predictable” consequences give the possibility to prepare for them before they run out of control. This is especially im- portant if further lockdowns would be neces- sary. Indirect consequences of a lockdown as fewer road and work accidents are positive side effects but not in the focus of discussion. Delayed treatment of acute diseases might lead to a higher disease burden later. At the moment there are no clear answers to this question. New is the situation of missed edu- cation for children. Here indirect health con- sequences might occur in form of psychoso- cial stress with long-term effects (49). As we do not know if these health-related problems are temporary or permanent, there is the need to monitor them to be aware of their preva- lence. Only by this, one can shift necessary resources to the area of need. There are al- ready clear signs that the austerity measures which followed the Financial Crisis of 2008 will not be applied by governments and the EU this time. In opposition, it is the first time that the EU is willing to go into debt itself. By this, further concerted actions regarding health issues become more, probably which will help to avoid the negative health effects of the recession. Satyamoorthy A, Brand H, van Kessel R. How to minimize negative health effects in the European Union due to the Economic recession caused by the COVID-19 Pandemic (Original research). SEE- JPH 2021, posted: 03 June 2021. DOI: 10.11576/seejph-4492 P a g e 12 | 15 References 1. World Health Organization. WHO Europe; 2020. Available from: http://www.euro.who.int/en/home (accessed: March 3, 2021). 2. World Health Organization. Corona- virus Disease Dashboard. WHO; 2020. Available from: https://covid19.who.int (accessed: March 3, 2021). 3. Politico. Coronavirus in Europe. Available from: https://www.polit- ico.eu/coronavirus-in-europe/ (ac- cessed: March 3, 2021). 4. European Commission. Preliminary flash estimate for the second quarter of 2020. EC; 2020. 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