Poverty, racism, and inequality merge with COVID-19 to create ‘syndemic’

A soldier in protective gear amid the COVID-19 pandemic stands guard in Ciudad Bolivar, an area with high cases of coronavirus in Bogota, Colombia, July 13, 2020. A homeless man without even a mask to protect himself sits in the street nearby. | Fernando Vergara / AP

The writer is a retired pediatric physician.

It didn’t seem to fit. The website of the Colombian Communist Party on Oct. 5 published a medical doctor’s reflections on re-characterizing a disease. Félix León Martínez, MD, quoted extensively from an editorial appearing in the famous British medical journal Lancet. He and Lancet editor Richard Horton, MD, claim that COVID-19 is not a disease but rather what Horton calls a “syndemic.”

A disease manifests signs and symptoms, and its cause or causes and treatment methods are usually well known. The assumption of both writers is that for COVID-19, ideas of cause and treatment are less well established, so far. In his article, Martínez draws from Horton’s editorial to analyze the COVID-19 situation in Colombia. The present report aspires to do likewise in regard to the United States, expanding upon Horton’s remarks in regard to management.

Martínez’s title is “From Pandemic to Syndemic: Poor Prognosis.” He indicates that “the [COVID-19] pandemic, although in principle a phenomenon of biological origin, affects each nation differently, according to the political, economic, and social organization it has established.”

Martínez is associated with the National University of Colombia, where he studies and writes about social protection. He serves as president of Colombia’s Foundation for Research and Development in Health and Social Security.

Horton, whom Martínez quotes extensively, states that, “We have viewed the cause of this crisis as an infectious disease … But … 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.”

As described by Horton, “Syndemics are characterized by biological and social interactions between conditions and states, interactions that increase a person’s susceptibility to harm or worsen their health outcomes … The hallmark of a syndemic is the presence of two or more pathological states that interact adversely with each other, adversely affecting the mutual course of each disease trajectory.” COVID-19, therefore, is more than a pandemic.

Horton observes, “For the world’s poorest billion people today, Noncommunicable Diseases (NCDs) account for more than one-third of their disease burden.” And, “The most important consequence of seeing COVID-19 as a syndemic is to highlight its social origins. The vulnerability of older citizens, black, Asian, and minority ethnic communities, and key workers, who are commonly underpaid and have fewer social protections, points to a hitherto barely recognized truth, namely that no matter how effective a treatment or protective vaccine is, the search for a purely biomedical solution to COVID-19 will fail.”

In his article, Martínez emphasizes Colombia’s extreme economic inequalities. For example, 10% of landholders own 82% of the productive land, and soon “three of every five persons in Colombia will be living in a state of precariousness or poverty,” and “24% of the vulnerable middle class will fall again into poverty.”

In Colombia, he notes, the rates of people dying from heart attacks, cerebrovascular illnesses, and hypertension—the three major causes of death—and from diabetes were increasing before COVID-19 appeared. Those conditions had become more prevalent too, along with obesity. For many Colombians, medical care for any illness is inaccessible and/or of poor quality. The burden of pre-existing illness on people infected with COVID-19, Martínez suggests, adds to the likelihood they will be terribly sick or die.

At this writing, nearly 29,000 Colombians have died from COVID-19. Colombia’s case fatality rate is 3.1%, the 10th highest in the world. Martínez cites a recent poll indicating that 16% of people in Bogota lack food and that 65% of households there include at least one person who is unemployed due to COVID-19.

The U.S. experience of COVID-19 also warrants taking a broad view of the situation. According to the CDC, Blacks, Indians, and Latinxs face at least 2.6 times the risk of being infected by COVID-19 as do white people. And COVID-19 death rates for Indians and Blacks are 1.4% and 2.1% greater, respectively, than the rate for white people.

But according to epidemiologist Sharrelle Barber, writing in the Lancet, “Blacks comprise 13% of the U.S. population but roughly one-quarter of COVID-19 deaths and are nearly four times more likely to die from COVID-19 compared to whites … Blacks across all age groups are nearly three times more likely than white people to contract COVID-19.”

Prior to the arrival of the virus, Black people and Latinxs were dying earlier from cancer, diabetes, hypertension, chronic respiratory disease, and other non-communicable diseases than were whites. Their life expectancy at age 50 is significantly less than the life expectancy for U.S. whites. Their previous ill health spells extreme danger when they are infected with COVID-19. Multiple studies have highlighted racial discrimination and racist attitudes that accompany their healthcare experience. The result frequently is inferior quality of care and reduced access.

The average African-American family income in 2018 was $41,361; for white families, $70,642. The poverty rate for African Americans that year was 20.8%, more than twice that of whites. Indeed, poverty alone predisposes Blacks and Latinxs to becoming seriously ill or dying from COVID-19. Low income often means reduced access to healthcare through inability to pay or lack of insurance. The result often is:  no regular healthcare providers, nutritional problems, crowded housing, and work situations where virus exposure may be expected. Nevertheless, effects of low income and racism often merge and are not easily separated for study.

Ideally, the practice of health care is collaborative. Physicians regularly seek help from colleagues who are knowledgeable about unfamiliar medical conditions or who offer special treatment skills. They seek consultation. Editor Richard Horton was advising infectious disease specialists to seek consultation in dealing with COVID-19. Specifically: “Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted [and] Unless governments design policies and programs to reverse the deep disparities, our societies will never be truly safe from COVID-19.”

Both Horton and Dr. Martínez in effect want political practitioners—politicians and the people’s movement—to take an active role in fashioning all-encompassing programs of prevention and treatment. They would be working toward a just society. When editors at pacocol.org publicized Martínez’s article, they were communicating that, in this case of a sick society, Colombian Communists would be joining the ranks of necessary consultants.

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CONTRIBUTOR

W. T. Whitney Jr.

W.T. Whitney Jr. is a political journalist whose focus is on Latin America, health care, and anti-racism. A Cuba solidarity activist, he formerly worked as a pediatrician, and lives in rural Maine.