As I write, there are more than 660,000 confirmed cases of COVID-19 and over 30,000 deaths across almost every country in the world, with infection rates accelerating everywhere except China (Centers for Disease Control, 2020). This acceleration is made very real to me simply because every time I return to this paper, these statistics must be updated by an ever-increasing number. Looking closer at this figures, data from China and Italy highlights that mortality rates increase not only with age, but also under the presence of what the press now ubiquitously and vaguely terms ‘pre-existing conditions’ (Guan et al., 2020). What we are therefore seeing is a syndemic of a novel, emerging infectious disease and a range of actually existing noncommunicable diseases (NCDs) across the world (Singer, 2000; Singer and Clair, 2003; Singer et al., 2017). COVID-19 is important because it lays bare how, as global rates of NCDs rise, so too does our collective vulnerability to communicable disease (Mendenhall, 2020). The rationalisation of mortality by reference to the ‘pre-existing conditions’ of the deceased glosses over this fact. Drawing attention to the syndemic nature of this pandemic is essential in order to ensure that ‘pre-existing conditions’ do not just become the backdrop or justificatory category against which COVID-19 mortality is documented, but rather are understood as a synergistic component of the disease trajectory itself.
We have long been cautioned about the ‘emerging infectious diseases’ that could materialise in the cracks left in underfunded healthcare and public health systems (Garrett, 1995; 2000). Indeed, Richard Krause, Anthony Fauci’s predecessor at the United States’ National Institute of Allergy and Infectious Diseases warned how ‘microbes pursue every possible avenue to escape from the barriers that are erected to contain them…they will seek our undercurrents of opportunity and re-emerge’ (Krause, 1998: 2). The 1992 report of the US Institute of Medicine, Emerging Infections: Microbial Threats to Health in the United States (Lederberg et al., 1992), was significant in providing a rationale for the national control of international diseases. The border closures and travel restrictions that characterised the first strategies of the Trump administration are a legacy of the securitised frame through which infectious disease outbreaks are largely understood in the global north: a distant problem of ‘elsewhere’ against which national borders must always be fortified (Herrick, 2019a). And yet COVID-19 has directly challenged that worldview by rapidly becoming a disease of everywhere. In so doing, it has painfully and dramatically drawn attention to our individual and societal vulnerabilities to the emergence of novel pathogens. Our present condition could accurately be described as ‘a synergy of epidemics [that] co-occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers’ (Swinburn et al., 2019). And yet, rarely in the incessant media reporting that now saturates our daily, lockdowned lives are these synergies discussed.
Over the past two decades, the prevalence of NCDs has increased dramatically across the world. This is especially the case in Low- and Middle-Income Countries, which also suffer the highest mortality rates from these conditions (World Health Organisation, 2018). Interestingly, the emerging infectious disease paradigm of the 1990s pointed to some of the same societal drivers – globalisation, urbanisation, changes in lifestyle and mass transportation (Krause, 1998)– that have also been at the heart of explanations for the rise in NCDs. Yet the exceptionalism of infectious disease outbreaks – not least for their proven capacity for economic devastation, rapid and high rates of mortality, pushing healthcare systems to collapse, paralysing global connectivity and requiring dramatic restrictions on individual liberties – means that the closely-tied ecologies of the communicable and noncommunicable tend to be overlooked (Seeberg and Meinert, 2015; Klusmeier, 2018). But even though the emerging infectious disease paradigm opened minds to the ever-present potential risk posed by novel pathogens (Weir and Mykhalovskiy, 2010), it did little to create environments that either fostered human resilience or reduced vulnerabilities (Farmer, 1996). We are now witnessing the disastrous effects of a lack of action to address these anticipated risks (Medenhall, 2020).
Singer and Clair, the original proponents of the concept, describe syndemics as ‘the temporal or locational co-occurrence of two or more diseases or health problems [and] the health consequences of the biological interactions among the health conditions present’ (2003: 423). In the case of COVID-19, data from China’s Centers for Disease Control (figure 1) shows that 10.5% of those with cardiovascular disease who were diagnosed with COVID-19 died, 7.3% of those with diabetes, 6.3% of those with chronic respiratory disease, 6% of those with hypertension and 5.6% of those with cancer. For those with no other health condition, the mortality rate was 0.9%. A similar pattern is borne out in Italy, where 99% of deaths were among those with at least one other health condition, with the highest rates among those with three or more illnesses (Ebhardt et al., 2020). In Italy, hypertension was the most common ‘pre-existing condition’. We are yet to see similarly detailed data from other countries, but it should be expected that these syndemic characteristics will be a characteristic of the outbreak across all countries.
The prevalence of chronic conditions clearly increases with age and this may help explain some national COVID-19 mortality patterns (Dowd et al., 2020). However, the exact nature of the ‘biological interaction’ between these noncommunicable diseases and COVID-19 is still largely unknown, although we do know that the more chronic conditions a person lives with, the more tempered their immune response (Mendenhall, 2020). The often-catastrophic costs associated with long-term chronic disease treatment across the world also layer onto the existing socio-economic, environmental and cultural disparities that amplify the risk of developing NCDs. And, as Vincanne Adams (2020) has argued, ‘the actual arrival of COVID-19 magnifies pre-existing vulnerability’, but the exact nature of these vulnerabilities are too often dissociated from the urgent drama of the COVID-19 response. This is why the use of the term ‘pre-existing condition’ – or even its synonym ‘underlying health condition’ – is so unhelpful. When UK Prime Minster Boris Johnson was diagnosed as positive for COVID-19, the press quickly speculated how there was little to fear as he had no ‘underlying health conditions’. In the UK, the term ‘vulnerable’ is now used to characterise a vast swathe of the population, from those over 70 who must now isolate themselves for at least 3 months, to those with particular ‘high risk’ medical conditions drawn from the NHS ‘shielded patient list’. Yet, in popular lexicon, the term ‘vulnerable’ has now become a catch-all for age and general health status. In our new socially distanced world, those with NCDs are now classed – and class themselves – as ‘vulnerable’. But this language erases the politics of that vulnerability – the genesis of the conditions themselves – and creates a flat earth in which NCDs themselves do not emerge, do not have a cause, but rather are always already existing. Perhaps most importantly, it also discounts the loss of life, as if mortality explained by virtue of the ‘pre-existing’ is somehow to be expected: a human tragedy, but one that can be explained. After all, they were ‘vulnerable’. In the long term, the pandemic of COVID-19 may well erase the ‘pandemic’ of NCDs (Allen, 2017)from the global health worldview unless the characteristics of this moment as a syndemic are explicitly acknowledged.
Crucially, such syndemics of the infectious and chronic, the communicable and noncommunicable, only serve to highlight just how concerned we should be about the potential effect of COVID-19 in Sub-Saharan Africa. Here, we find significant triple and quadruple burdens of infectious, perinatal and maternal, and noncommunicable diseases, as well as high rates of injury and trauma. Here, the justificatory addendum of the ‘pre-existing condition’ may well not be possible because of gross gaps in diagnosis and treatment for NCDs across the continent (Herrick and Reubi, 2017), but that is not to say that they were not present. It is worth remembering Singer’s early assertion that, ‘a syndemic is a set of closely intertwined and mutual enhancing health problems that significantly affect the overall health status of a population within the context of a perpetuating configuration of noxious social conditions’ (2000: 13). Amid the global rush to scale-up ICU beds, attain PPE, ventilators, argue about the merits of testing, social distancing and containment measures; the interaction of COVID-19 with ‘noxious social conditions’ have not yet strayed far beyond the spaces of healthcare delivery or the politics of access to testing. Yet, the inequalities patterning the ‘pre-existing conditions’ that now guard the line between life and death – as so eloquently discussed by journalist Nick Cohen (2020) – are among the most noxious of social conditions.
If the COVID-19 pandemic lays bare our collective vulnerabilities to emerging infectious disease, the differential genesis of these vulnerabilities must be foregrounded and not merely footnoted in news and data reporting. COVID-19 has made ‘pre-existing conditions’ somehow innocuous. As the days of lockdown wear on, the gripping story of this pandemic has become when someone dies without a pre-existing condition – the exception that serves to scare us all. But, NCDs now affect the majority of the world’s population and political prioritisation and financial resources remain woefully inadequate (Herrick, 2019b). The fact that COVID-19 reveals this in such stark, but underacknowledged ways – must not be the postscript to this pandemic. The potential for future pandemics will only be further magnified by sidelining NCDs in the frenzy of the emergency response. Indeed, as the long-term social and economic consequences of this outbreak unfold, inequalities are likely only to deepen, public health resources will be stretched still further, healthcare systems recalibrated for these exceptional times will need to be quickly retooled and our political and moral landscapes may be forever changed. It will not be business as usual. But my fear is that even as the viral threat ebbs and our daily lives slowly re-emerge; the underlying health, economic and social drivers of this pandemic will remain just as they ever were.
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Dr Clare Herrick is a Reader in Human Geography at King’s College London where she has worked since 2007. Her research explores the intersections between health behaviours, risk, regulation and urban environments across a range of geographic contexts. You can find out more about her research and writing here.