For the last 25 years, in my work as an applied medical anthropologist, I have called attention to and explored syndemics, the biosocial adverse interaction of two or more diseases and the social conditions of the local or regional context in which they occur. The study of syndemics offers a way to address both health risks and unjust and harmful social arrangements, and an approach for mounting structural interventions to prevent extensive social suffering, illness, and death.

One kind of syndemic of growing concern is the ecosyndemic, which involves the environmental mediation of disease interaction. Of particular recent concern is the study of the intersection between the ongoing health effects of 9/11 and the spread of COVID-19. In notable numbers, first responders exposed to a mix of toxins as they worked to save lives at Ground Zero are now dying from a viral disease that attacks their already damaged lungs and immune systems. 9/11 first responders have an increased risk profile for developing cancer (Shapiro et al 2019), a noted preexisting condition that puts people at high-risk for COVID-19. The consequences of this destructive ecosyndemic are exemplified by the fact that almost half of New York City Fire Department 9/11 medical responders have contracted COVID-19, according to Oren Barzilay, president of Local 2507, a union that represents emergency medical technicians, paramedics, and fire inspectors. Thus far, the CDC has identified almost 7,000 confirmed cases of COVID-19 in 9/11 responders and survivors (CDC 2021). According to the Centers for Disease Control and Prevention (CDC), 29 survivors of 9/11 and 68 first responders enrolled in the World Trade Center Health Program (WTCHP) had died from the virus by the end of August 2021. Advocates point out that the actual death toll is in fact far higher, as thousands of first responders with 9/11-related diseases never joined the WTCHP.

The connections between cancer and increased susceptibility to and more adverse outcomes with COVID-19 are still not fully elucidated. It has long been hypothesized that patients with cancer are more vulnerable to viral infections. In part, this seems to be because cancer and certain treatments for it can weaken the immune system and compromise the body’s ability to fight off or withstand infection. Additionally, cancer is linked with arterial hypertension and cardiomyopathy, both of which exacerbate COVID-19’s hallmark symptoms and their effects. The susceptibility of patients with cancer to COVID-19 infection and more adverse outcomes depends on several factors, including the type of cancer, the stage of development of the cancer, and the course of treatment, such as chemotherapy, a patient has received.

For many years before COVID-19, I studied AIDS in low-income, ethnic minority populations in Hartford, CT and Springfield, MA. We learned from the ongoing AIDS pandemic the value of remembering and honoring the lives of individuals who died from the disease (often in interaction with other diseases). Steven Brandow is one of the people fatally affected by the toxic exposure/COVID-19 syndemic worthy of honoring. Brandow was one of the NYPD officers who dug through the smoldering rubble at Ground Zero, looking at first for survivors of the attacks, and later for the lifeless bodies of those killed in the collapsed towers. Although he had led an active life as a skier, SCUBA diver, fisherman, ice hockey player and Giants fan, in February 2021, Brandow died of COVID-19 and 9/11-related diseases at age 56.

Toxic exposure/COVID-19 syndemics affect far more people in the U.S. and elsewhere than those involved in the events of 9/11. A second ecosyndemic linking COVID-19 and environmental toxins is being driven by climate change. According to a study led by Francesca Dominici (Science Advances 2021), thousands of COVID-19 cases and deaths in California, Oregon, and Washington in 2020 may be linked to inhaling fine particulate air pollution (namely particles with an aerodynamic diameter of 2.5 microns or smaller) from wildfire smoke. From September 14-17, 2020, for example, Mono County, California residents endured four consecutive days with hazardous PM2.5 levels during the Creek Fire. Smaller particles can reach the deepest parts of the lung known as the alveolar region, where the vital gas exchange of oxygen and carbon dioxide occurs. This short-term exposure caused respiratory system damage resulting in or exacerbating conditions like asthma and chronic obstructive pulmonary diseases (COPD), putting people at increased risk of adverse COVID-19 outcomes.

Killer commodity production drives a third example of COVID-19 ecosyndemics. In 2011, I published a paper entitled “Down Cancer Alley: The Lived Experience of Health and Environmental Suffering in Louisiana’s Chemical Corridor” (Singer 2011). The paper was based on a study I did in the town of Donaldsonville, the parish seat of Ascension Parish, Louisiana. The study took place during the Deepwater Horizon oceanic spill that leaked about 5 billion barrels of oil into the Gulf. For the people of Ascension, and especially the majority low-income Black population of Donaldsonville, this event only enhanced their awareness of their vulnerability to the petrochemical industry. Ascension is home to 14 major manufacturing companies involved in the production of chemicals, plastics, fertilizers, and other products from Gulf oil. The preponderance of such factories along the 85-mile stretch of the Mississippi from New Orleans to Baton Rouge has, for good reason, led the area to be known colloquially as the “Chemical Corridor” or “Cancer Alley.” The Alley is a major reason Louisiana ranks among the top states in per capita production of toxic wastes as well as in the volume of hazardous toxins like ammonia, chlorine, hydrogen cyanide, sulfuric acid, hydrochloric acid, and chloroprene, discharged into its water, air, and soil.

Health activists long have argued that living in the Alley has severely harmed the health of local residents. They point out that Louisiana’s population is ranked as having the 47th worst health record among the 50 states, including suffering from a high premature death rate. Research summarized in my paper shows that people living in the Alley who get their drinking water from the Mississippi River have as much as a two times greater chance of developing rectal cancer compared to residents who get their water from other sources. Further, cancer rates in Louisiana are highest in or downstream from the Alley. Also people in southern Louisiana who live within one mile of a petrochemical plant have 4.5 times greater odds of developing lung cancer compared to those who live at greater distance. In 2005, the overall cancer rate in Louisiana was approximately 17 percent higher than the national average especially among Black men and to a somewhat lesser degree among Black women. According to the CDC-linked Louisiana Cancer Control Partnership, Black people in Louisiana bear an unequal burden of cancer compared to their white neighbors. It is no surprise then that people living in the Alley can recite the names of the multiple relatives that have been diagnosed with or died of cancer.

Now COVID-19 has come to the Alley. In a six-part series aired in October 2020, USA TODAY reported people in the Alley have a notably high COVID-19 death rate. St. John the Baptist Parish, which borders Ascension, has double the state COVID-19 death rate. Nearly 60% of the parish’s COVID-19 victims are Black. In the words of one resident interviewed by reporters: “This is a result of historical racism…We’ve gotten the worst of everything, and we’re getting the worst of this.”

One of the main routes of human exposure to killer commodity immunotoxins is through drinking water. As noted, the effectiveness of immune response is of concern among people exposed to the COVID-19 virus. Researchers are worried that various metals, plastic components, plasticizers, and per- and polyfluoroalkyl substances found in drinking water may exacerbate COVID-19 respiratory symptoms. Some of these substances are also linked to cardiovascular system damage, diabetes, and cancer, conditions associated with more severe COVID-19 consequences. For example, the CDC’s Agency for Toxic Substances and Disease Registry has reported that several studies suggest that exposure to high levels of “forever chemicals” like fluorinated compounds, substances commonly referred to as PFAS, may suppress the human immune system and increase both the risk of getting COVID-19 as well as the severity of infection. In a July 2020 essay in the Environmental Health News, a group of leading PFAS researchers stated “Most concerning during this global pandemic … is that exposure to PFAS suppresses the ability of the immune system to make antibodies — the part of the immune system critically important in fighting COVID-19 and other infectious agents” (2020).

PFAS have been in use since the 1940s to make products that are non-stick, waterproof or stain-resistant. In North Carolina, for example, two companies, DuPont and Chemours produce PFAS at chemical plants near the banks of the Cape Fear River in Bladen County. In 2017, the Wilmington Star-News disclosed that high levels PFAS had been found in the downstream drinking water of New Hanover, Pender and Brunswick counties. It has been estimated that 200,000 people get their drinking water from the Cape Fear River below the chemical factories. One of them is John Wolfe, a Wilmington boat captain. The North Carolina Health News reports that Wolfe’s blood was found to have elevated levels of two types of PFAS called Nafion by-product 1 and Nafion by-product 2 which have been used in the manufacturing process by both DuPont and Chemours in fuel cell technology, metal plating, hydrogen production, paints, and chlorine production. Despite closely following CDC prevention guidelines, Wolfe worries he is at very high risk for COVID-19.

These four cases of likely toxic exposure/COVID-19 syndemics are, no doubt, only the tip of the iceberg in a highly polluted world. As Ronald Kostoff and colleagues wrote recently in the Food Chemical Toxicology, the “attribution of serious consequences from COVID-19 should be made to the virus-toxic stressors nexus, not to any of the nexus constituents in isolation” (2020). It is not just COVID-19, but the understudied toxin/virus nexus that must be understood and addressed. Given that syndemics were first described in medical anthropology and a growing number of anthropologists have been involved in syndemics research, our field is positioned to play a key role in bringing toxic exposure/COVID-19 syndemics to light and diminishing viral impact now and in the future.

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Merrill Singer, PhD., is Emeritus Professor of Anthropology and Senior Research Scientist, at the Center for Health, Intervention and Prevention, at the University of Connecticut. Dr. Singer’s work has focused on infectious disease and environmental health including work on HIV/AIDS, STIs, hepatitis, Ebola, tick-borne diseases, COVID-19, arbovirus diseases. He is the author of 34 books, and over 230 peer-reviewed articles. Social justice, the social determinants of health, syndemics, and critical medical anthropology have been enduring themes of his research and applied work.

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Works Cited

Shapiro MZ, Wallenstein SR, Dasaro CR, Lucchini RG, Sacks HS, Teitelbaum SL, Thanik ES, Crane MA, Harrison DJ, Luft BJ, Moline JM, Udasin IG, Todd AC. Cancer in General Responders Participating in World Trade Center Health Programs, 2003-2013. JNCI Cancer Spectr. 2019 Nov 6;4(1):pkz090. doi: 10.1093/jncics/pkz090. PMID: 32337498; PMCID: PMC7050150. 

Christopher J. Eberhart and Nancy Cutler, Rockland/Westchester Journal News (2021) For those who risked their life during and after the 2001 attacks, the threat of COVID-19 was magnified by vulnerabilities and the echo of trauma. USA Today  (May 5). https://www.usatoday.com/in-depth/news/nation/2021/05/05/covid-risk-911-september-2001-ground-zero-responders-causes-concern/4961779001/ 

Merrill Singer. Down Cancer Alley: The Lived Experience of Health and Environmental Suffering in Louisiana’s Chemical Corridor. Medical Anthropology Quarterly 25(2): 141-163, 2011. 

Xiaodan Zhou, Kevin Josey, Leila Kamareddine, Miah C. Caine, Tianjia Liu, Loretta J. Mickley, Matthew Cooper and Francesca Dominici 2021 Excess of COVID-19 cases and deaths due to fine particulate matter exposure during the . 2020 wildfires in the United States. Science Advances https://www.science.org/doi/pdf/10.1126/sciadv.abi8789 

Jamie Dewitt , Phil Brown , Courtney Carignan , Shaina Kasper , Laurel Schaider , Cheryl Osimo and Maia Fitzstevens 2020 PFAS chemicals—the other immune threat. Environmental Health News https://www.ehn.org/pfas-and-immune-system-2646344962.html 

Vaughn Hagerty 2017 Toxin taints CFPUA drinking water Wilmington Star-News https://www.starnewsonline.com/story/news/environment/2017/06/07/toxin-taints-cfpua-drinking-water/20684831007/ 

Ronald Kostoff, Michael B. Briggs, Alan L. Porter, Antonio F. Hernández, Mohammad Abdollahi, Michael Aschner and Aristidis Tsatsakis 2020 The under-reported role of toxic substance exposures in the COVID-19 pandemic. Food Chemical Toxicology 145: 111687. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426727/ 

Cited in: SAMANTHA MALDONADO 2021  COVID Death Toll Among 9/11 First Responders and Survivors Nears Grim Milestone. The City (September 29). https://www.thecity.nyc/2021/9/9/22665844/covid-death-toll-sept-11-responders-survivors-grows