The COVID-19 syndemic is not global: context matters
Authors: Emily Mendenhall
Journal: The Lancet (2020)

Richard Horton recently called COVID-19 a syndemic.1Horton R Offline: COVID-19 is not a pandemic.Lancet. 2020; 396: 874Summary Full Text Full Text PDF PubMed Scopus (632) Google Scholar He aptly used this concept to describe how COVID-19 clusters with pre-existing conditions, interacts with them, and is driven by larger political, economic, and social factors.2Singer M Bulled N Ostrach B Mendenhall E Syndemics and the biosocial conception of health.Lancet. 2017; 389: 941-950Summary Full Text Full Text PDF PubMed Scopus (796) Google Scholar Calling COVID-19 a global syndemic is misguided. Syndemics matter because they focus on what drives diseases to cluster and interact.3Mendenhall E Beyond comorbidity: a critical perspective of syndemic depression and diabetes in cross-cultural contexts.Med Anthropol Q. 2015; 30: 462-478Crossref PubMed Scopus (72) Google Scholar What is driving coronavirus to move through the population in the USA and interact with biological and social factors, however, differs from other contexts. US political failures have driven COVID-19 morbidity and mortality, and this cannot be divorced from our historical legacy of systemic racism4Laster Pirtle WN Racial capitalism: a fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States.Heal Educ Behav. 2020; 47: 504-508Crossref Scopus (375) Google Scholar or our crisis of political leadership.5Altman D Understanding the US failure on coronavirus—an essay by Drew Altman.BMJ. 2020; 370m3417Crossref PubMed Scopus (36) Google Scholar This matters because in other contexts COVID-19 is not syndemic. New Zealand's political leadership in response to the crisis has been exemplary.6Wilson S Three reasons why Jacinda Ardern's coronavirus response has been a masterclass in crisis leadership.http://theconversation.com/three-reasonswhy-jacinda-arderns-coronavirus-response-has-been-a-masterclass-incrisis-leadership-135541Date: April 5, 2020Date accessed: October 19, 2020Google Scholar COVID-19 is not syndemic there. In this sense, syndemics allow us to recognise how political and social factors drive, perpetuate, or worsen the emergence and clustering of diseases. Recognising contexts are different matters a great deal. For instance, contexts throughout sub-Saharan Africa are doing much better than the most burdened contexts, like the USA, Brazil, and India. Many people have questioned, why? Some have argued that this reflects a racist frame thinking that African contexts should suffer more.7Nyabola N How to talk about COVID-19 in Africa.http://bostonreview.net/global-justice/nanjala-nyabola-how-talk-about-covid-19-africaDate: Oct 15, 2020Date accessed: October 19, 2020Google Scholar Yet, many African governments acted more swiftly and confidently than wealthier countries. The political leadership in these contexts, therefore, prevented the extensive death tolls, compared to contexts like the UK and the USA, where political leadership failed. Recognising political determinants of health is central to the syndemic construct. By calling the COVID-19 syndemic global, we miss the point of the concept entirely. I do not write this to dampen Horton's use of the term, as I believe COVID-19 is syndemic in my country (the USA). This is precisely because pre-existing conditions such as hypertension, diabetes, respiratory disorders, systemic racism, mistrust in science and leadership, and a fragmented health-care system have driven the spread and interacted with the virus. These synergistic failures have caused more death and devastation than many other contexts. Recognising failures of wealthy countries is imperative as we think about where global knowledge and power sit within fields like global health. Syndemic frames provide us with an opportunity to do this. I declare no competing interests. Offline: COVID-19 is not a pandemicAs 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. Full-Text PDF