COVID-19: The New Syndemic

Dr Varthani Kirupanandan MBChB, for the Commonwealth Medical Trust

Since the very first case of COVID-19 was detected in Wuhan, Hubei Province, China, the number of cases worldwide has grown exponentially.  COVID-19 was declared a pandemic by the World Health Organization on 11 March 2020,¹   and currently there are more than 43,500,000 cases and more than 1,160,650 deaths worldwide. COVID-19 has also had a devastating impact on the global economy, worse than the 2009 financial crisis². It is expected to result in an increase in starvation³ and has altered the education and working sector significantly.

A pandemic is defined as ‘an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.’⁴ And whilst this definition does depict the spread of COVID-19, it has limitations in encompassing the different dynamics involved in disease transmission. Dr Richard Horton, editor of The Lancet, released an article entitled “COVID-19 is not a pandemic”⁵, describing how it is a syndemic and should be tackled as such, introducing a new perspective to the situation.

The term syndemic was first used by medical anthropologist Merrill Singer in the 1990s to depict the overlap of epidemics with one another as well as with social, economic and cultural disparities.⁶ A syndemic approach means looking at COVID-19 from more than a virology perspective. It means  also looking at the social and economic variants which are affecting how COVID-19 is transmitted and causes significant morbidity and mortality. 

A syndemic approach to coronavirus also means creating policies and plans which address non-communicable diseases (NCDs), as they have been shown to increase an individual’s susceptibility and increase risk of an adverse outcome from coronavirus.  NCDs are chronic conditions which cannot spread from person-to-person, ie conditions such as diabetes mellitus, hypertension, asthma, obesity and cardiovascular disease.

This all-rounded approach is not limited to analyzing medical comorbidities which affect people, but also look at the different socio-economic factors. NCDs disproportionately affect those living in low-income countries, and there is a relation between poverty and prevalence of non-communicable disease⁷. To fully get to grips with the social and economic influences in this pandemic and in the NCD pandemic, we need to tackle smoking, alcohol intake and sugar based diets.

Furthermore, an all-encompassing COVID-19 mitigation plan will not be complete without acknowledgement of the social groups who are at higher risk of adverse morbidity or mortality. Black Asian and Minority Ethnic (BAME) individuals have been statistically shown to be at higher risk of becoming unwell from the virus, requiring hospitalization, intensive care, or dying from the disease.⁸ Older people are more vulnerable to its effects and account for the vast majority of deaths.^{9 10}  Moreover, key workers - doctors, nurses, cleaners, teachers and delivery staff to name a few, have been at the forefront of this battle. Many of these  key workers are poorly paid⁵, and across the board they may have struggled with access to personal protective equipment (PPE) and welfare.  In the United Kingdom, for example, 10.6 million people are classified as key workers, and their job role places them at a higher risk of COVID-19. To plan fully for a resolution to COVID-19 we need to plan to work towards mitigating the risks that these social groups have and protecting their health.¹¹

Ultimately, just tackling COVID-19 from an infectious diseases perspective will not allow us to provide a holistic plan to address this virus which has toppled our way of life.  To fully address this challenging disease, we need to acknowledge the importance of addressing the multiple factors in play, and only then can we truly create a comprehensive approach to COVID-19.

References

¹ World Health Organization. Rolling Updates on coronavirus disease. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen

²OECD. G20 GDP Growth - Second quarter of 2020, OECD. Available from: http://www.oecd.org/sdd/na/g20-gdp-growth-second-quarter-2020-oecd.htm

³ BBC News. Coronavirus: UN makes record $10.3bn appeal for pandemic fight. Available from: https://www.bbc.co.uk/news/world-53439535

⁴Last JM, editor. A dictionary of epidemiology, 4th edition. New York: Oxford University Press; 2001

⁵Richard Horton. Offline: COVID-19 is not a pandemic. The Lancet. 2020; 396 (10255): 874. Available from: https://doi.org/10.1016/S0140-6736(20)32000-6

⁶Jason Daley. Syndemic: The Little-Known Buzzword That Describes Our Troubled Times. Smithsonian Magazine. Available from: https://www.smithsonianmag.com/smart-news/syndemic-little-known-buzzword-describes-our-troubled-times-180971381/

⁷Luke Allen et al. Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review. Lancet Glob Health  2017 Mar;5(3):e277-e289. Available from: https://pubmed.ncbi.nlm.nih.gov/28193397/

⁸Public Health England. Beyond the data: Understanding the impact of COVID-19 on BAME groups. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf

⁹Rebecca Irons. Pandemic … or syndemic? Re‐framing COVID‐19 disease burden and ‘underlying health conditions.’ Social Anthropology. Available from: https://onlinelibrary.wiley.com/doi/10.1111/1469-8676.12886

10 CDC Centre for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Older Adults. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

11 The Lancet. The plight of essential workers during the COVID-19 pandemic. 2020 23-29 May; 395(10237): 1587. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241973/