As the world approaches 1 million deaths from COVID-19, we must confront the fact
that we are taking a far too narrow approach to managing this outbreak of a new coronavirus.
We have viewed the cause of this crisis as an infectious disease. All of our interventions
have focused on cutting lines of viral transmission, thereby controlling the spread
of the pathogen. The “science” that has guided governments has been driven mostly
by epidemic modellers and infectious disease specialists, who understandably frame
the present health emergency in centuries-old terms of plague. But what we have learned
so far tells us that the story of COVID-19 is not so simple. Two categories of disease
are interacting within specific populations—infection with severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) and an array of non-communicable diseases (NCDs).
These conditions are clustering within social groups according to patterns of inequality
deeply embedded in our societies. The aggregation of these diseases on a background
of social and economic disparity exacerbates the adverse effects of each separate
disease. COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the
threat we face means that a more nuanced approach is needed if we are to protect the
health of our communities.
© 2020 Peter Scholey Partnership/Getty Images
2020
Since January 2020 Elsevier has created a COVID-19 resource centre with free information
in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre
is hosted on Elsevier Connect, the company's public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related research that is
available on the COVID-19 resource centre - including this research content - immediately
available in PubMed Central and other publicly funded repositories, such as the WHO
COVID database with rights for unrestricted research re-use and analyses in any form
or by any means with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
The notion of a syndemic was first conceived by Merrill Singer, an American medical
anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall
and colleagues, Singer argued that a syndemic approach reveals biological and social
interactions that are important for prognosis, treatment, and health policy. Limiting
the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic
inequality than has hitherto been admitted. A syndemic is not merely a comorbidity.
Syndemics are characterised by biological and social interactions between conditions
and states, interactions that increase a person's susceptibility to harm or worsen
their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite
for successful containment. As our recently published NCD Countdown 2030 showed, although
premature mortality from NCDs is falling, the pace of change is too slow. The total
number of people living with chronic diseases is growing. Addressing COVID-19 means
addressing hypertension, obesity, diabetes, cardiovascular and chronic respiratory
diseases, and cancer. Paying greater attention to NCDs is not an agenda only for richer
nations. NCDs are a neglected cause of ill-health in poorer countries too. In their
Lancet Commission, published last week, Gene Bukhman and Ana Mocumbi described an
entity they called NCDI Poverty, adding injuries to a range of NCDs—conditions such
as snake bites, epilepsy, renal disease, and sickle cell disease. For the poorest
billion people in the world today, NCDIs make up over a third of their burden of disease.
The Commission described how the availability of affordable, cost-effective interventions
over the next decade could avert almost 5 million deaths among the world's poorest
people. And that is without considering the reduced risks of dying from COVID-19.
© 2020 Allison Michael Orenstein/Getty Images
2020
Since January 2020 Elsevier has created a COVID-19 resource centre with free information
in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre
is hosted on Elsevier Connect, the company's public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related research that is
available on the COVID-19 resource centre - including this research content - immediately
available in PubMed Central and other publicly funded repositories, such as the WHO
COVID database with rights for unrestricted research re-use and analyses in any form
or by any means with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
The most important consequence of seeing COVID-19 as a syndemic is to underline its
social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic
communities; and key workers who are commonly poorly paid with fewer welfare protections
points to a truth so far barely acknowledged—namely, that no matter how effective
a treatment or protective a vaccine, the pursuit of a purely biomedical solution to
COVID-19 will fail. Unless governments devise policies and programmes to reverse profound
disparities, our societies will never be truly COVID-19 secure. As Singer and colleagues
wrote in 2017, “A syndemic approach provides a very different orientation to clinical
medicine and public health by showing how an integrated approach to understanding
and treating diseases can be far more successful than simply controlling epidemic
disease or treating individual patients.” I would add one further advantage. Our societies
need hope. The economic crisis that is advancing towards us will not be solved by
a drug or a vaccine. Nothing less than national revival is needed. Approaching COVID-19
as a syndemic will invite a larger vision, one encompassing education, employment,
housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such
a broader but necessary prospectus.
© 2020 xavierarnau/Getty Images
2020
Since January 2020 Elsevier has created a COVID-19 resource centre with free information
in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre
is hosted on Elsevier Connect, the company's public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related research that is
available on the COVID-19 resource centre - including this research content - immediately
available in PubMed Central and other publicly funded repositories, such as the WHO
COVID database with rights for unrestricted research re-use and analyses in any form
or by any means with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre remains active.