A syndemic approach to the pandemic

With the havoc being wrought by COVID-19 on our health system, a fixation on daily statistics of infection, deaths, and recovery is inevitable. However, the focus on the pandemic’s collateral damage to other health issues—which by themselves can foretell a silent crisis within this crisis—is wanting, and that is troubling.

Articulating the fact that most COVID-19 cases are not severe doesn’t help. The message that is not getting across is that, of the severe cases that mostly lead to deaths, underlying health conditions—not SARS-CoV-2 (the virus causing the pandemic) per se—are the final nails in the coffin.

These are hypertension, cardiovascular diseases, diabetes, chronic lung diseases—major non-communicable diseases (NCDs) that are our top causes of premature deaths before the onset of COVID-19—and very possibly, as modeling studies are indicating, even long after the resolution of this pandemic.

Never shall the twain of communicable diseases and non-communicable diseases meet, so it’s been said. This is downright false. The COVID-19 and NCDs syndemic (or synergistic epidemic), a dangerous combination of two or more health conditions working together in synergy to amplify already poor health outcomes that are produced by each other, needs to be examined.

NCDs can predispose people to COVID-19 infection and complicate its course. SARS CoV-2 can also trigger or exacerbate NCDs. This double disaster is already staring us in the eye, but all that we see at this time is the pandemic.

A syndemic approach—looking at COVID-19’s interplay with other health conditions, analyzing their interactions, and, most importantly, addressing the social, economic, and environmental factors that determine all of these—is warranted.

Despite breakthroughs in the understanding of the causation and treatment of NCDs, these slowly moving pandemics (because of their global disease burden) are mediated by risk factors such as obesity, smoking, excessive alcohol intake, and sedentary lifestyles.

More importantly, they are aggravated by health inequities that are largely underpinned by poverty in our setting. These make people with NCDs, especially poor ones, highly vulnerable to COVID-19.

While science is emerging to explain the novel interactions between COVID-19 and NCDs, we have to reconsider and hype up the usual strategies to address NCDs in ways that can be related to our COVID-19 response.

Aside from following the minimum health standards (use of masks, washing of hands, safe distancing) in the new normal, we should not forget to prescribe and adopt healthy lifestyle behaviors on proper nutrition, regular physical activity, and healthy coping mechanisms. If quarantine measures facilitated COVID-19 health protocols, the same measures also disrupted healthy, well-balanced living for many.

With restricted mobility and decreased access to routine health services because of the “covidization” of health care and fear of contracting the virus, people are staying home, only to develop or enhance their NCD risk factors because of the following: inadequate and suboptimal nutrition due to lack of access to fresh food and diminished food options; lack of physical activity; difficulty in accessing medicines because of supply issues and difficulty in refilling prescription; and issues in follow-up and monitoring with the decrease in doctors’ appointments and interruption of non-COVID-19 services.

We should start looking at pandemic interventions as the same measures needed to arrest the onslaught of NCDs and other diseases and health conditions. Enhanced disease surveillance, improved health literacy, upgraded health care infrastructure, a whole-of-society approach—these should work for any health problem.

Finally, not all is lost if we only address existing health inequity issues that have been magnified by the pandemic.

In a country where health remains a privilege enjoyed by the few and access to services is dictated by one’s position in the social and economic strata, we must aim to fix our health system and prioritize the poor and marginalized—the silent majority who are used to living (suffering) from one health crisis to the next.

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Ronald Law, a public health physician specializing in emergencies and disasters, is a professor of public health and a Fulbright scholar.