28 Sep Understanding the Systems we Live in: Deconstructing the Systems we Live by

Syndemic view: What it is & how it is relevant in the context of the COVID-19 pandemic:

The concept of syndemic was coined by medical anthropologist Merrill Singer in the 90s to describe the way epidemics can overlap with social and cultural problems in a way that the damaged caused is more hindering than just “the sum of the parts”, making the population even more vulnerable to their impact.

More than the notion that many interrelated factors may work together to worsen the intensity and damage of a health crisis population within the context of a perpetuating configuration of noxious social conditions, the syndemic approach underlines:

• The importance of the disease clustering within populations,
• The social, psychological, and biological reasons that diseases cluster,
• The ways comorbid diseases affect each other,
• How important these interactions can be to the health burden within the populations,
• The pathways of disease interaction,
• The way in which the health of human beings is affected by the physical and social environments in which they live.

In the context of COVID-19 pandemic, we see a combination of the disease caused by the new coronavirus and pre-existing conditions (e.g., non-communicable diseases: hypertension, obesity, diabetes, cardiovascular diseases, cancer, etc.) that affect the world’s population in a disproportionate way, which fuelled by inequalities result in adverse outcomes in disadvantaged, low-income, and ethnic minority communities. In the case of COVID-19, as the editor-in-chief of the Lancet (Richard Horton) argues, attacking non-communicable diseases is a prerequisite for successfully combating the current crisis, paying particular attention to these in poorer countries.

Moreover, populations affected by food insecurity, climate change, and housing conditions make it difficult to follow sanitary recommendations, such as washing hands or maintaining social distance. In order to contain the advance and impact of the coronavirus, it’s critical to also pay attention to the social conditions that make certain groups more vulnerable to the disease’s consequences, as well as more vulnerable to being infected. Looking at the situation through the lens of the syndemic approach allows us to move from epidemiology’s classic approach to transmission risk to a view of the person in their social context.

However, accounting for social determinants of health might not be enough if we do not also account for structural and systemic factors which interact with deeply rooted patterns of inequality in our societies. More than developing effective treatments and vaccines, if governments and power structures do not implement adequate and timely policies to lessen systemically rooted disparities, our societies will never be truly safe from COVID-19 and the pandemics that will follow.

The COVINFORM project, goes beyond that in bringing together other approaches which allow us to better understand the socio-economic impacts of COVID-19 enhanced by pre-existing social disparities, as well as the dynamics between the several systems that make up a society: Intersectionality and Socio-Ecological Systems Framework.

COVINFORM frames: Why syndemics is NOT ENOUGH & How Social Sciences are imperative for the solution:

Many of the communities hardest hit by COVID-19 were already facing other public health challenges (e.g., high levels of stress and trauma, unemployment, discriminatory treatment in healthcare system, etc.). In this way, the syndemic approach involves three rather important claims:

1. Political-economic forces with historical depth lead to entrenched social, economic and power inequities.
2. Those inequities shape the distribution of risks and resources for health, leading to the concentration of disease in specific parts of a population.
3. Some overlapping diseases make one another worse because of biological interactions.

Interestingly, medical anthropologist Emily Mendenhall states that “COVID is not inherently syndemic”. Since syndemics are not properties of diseases but rather properties of systems, we must account for complex, real-world interactions among political-economic structures, ecological contexts, and human biology. In this view, what drives the coronavirus to move through different populations and interact with biological and social factors differs between contexts – therefore, “calling COVID-19 a global syndemic is misguided”. Syndemics allow us to recognise how political and social factors drive, perpetuate, or worsen the emergence and clustering of diseases. In countries (e.g., USA) where political failures have driven COVID-19 morbidity and mortality, we cannot dismiss the historical legacy of systemic racism or crisis of political leadership and thus, COVID-19 is syndemic in the context of that country. Recognising contexts are different matters a great deal.

The past plays indeed a significant role in comprehending the present and preparing for the future. Although syndemics acknowledges the existence of political and economic factors, it fails to address them in a deeper way. The severity of the pandemic may also be attributed to the austerity policies enforced following the 2008 financial crisis, which adversely affected the most marginalized groups and weakened essential services. Budget cuts and a focus on efficiency rendered the healthcare system unprepared to cope with a significant shock. In many countries, the COVID-19 pandemic revealed a lack of resilience of health systems and additional financing is required to provide countries with the agility to respond to future crises. It is of utter importance to consider the systems’ history and context when trying to understand their current situation and make predictions about future ones.

Moreover, Emily Mendenhall also highlights that the accumulated advantages of whiteness meant that white people were more likely to be in professions that allowed them to work from home, reducing exposure. The same goes for jobs with poor working conditions being predominantly occupied by women. Even more so when, for instance, precarious cleaning jobs are occupied by older migrant women with low socio-economic status who are also the primary (or only) care takers within their family. These social inequalities associated with poor health conditions and less resources to fight the disease (e.g., using public transportation) aggravate the already existing vulnerabilities.

A syndemic approach does not also allow a deeper understanding of the intertwined nature of race, class, gender, sexual orientation, among other, in terms of what it can tell us about structural and social dimensions of health. In contrast, an intersectional analysis offers “context” to interpret syndemic analysis, as well as an intersectional framework might prevent a potential syndemic from occurring. The commentary on syndemics and intersectionality by Sangaramoorthy and Benton provides more insights on how the syndemic approach lacks in accounting for the complex dynamics, ideologies, and institutions shaping vulnerable groups’ health and well-being.

The COVINFORM project combines an Intersectional approach (read more here) with a Socio-ecological System (SES) frame to enable a global analysis of the different populations we study, the contexts they live in, and the norms they live by. Each system has its own norms, resources, measures, and outputs that shape people’s lives, experiences, and well-being. Their characterization through a SES framework paves way to a better understanding of cumulative and synergic factors, as well as the whole dynamic of vulnerabilities and responses which contribute to the enhancement or mitigation of COVID-19 impacts, throughout different points in time.

Moreover, System’s resilience (particularly that of health systems and social services) is key to coping with events such as this. If we take resilience as “the ability to plan and prepare for, absorb, recover from, and adapt to adverse events”, it is the balance between vulnerability factors and protective factors that dictates the degree of resilience of a given system or population, that is, its ability to adapt and recover, reducing the impacts caused by the COVID-19 threat. Vulnerability factors increase people’s exposure to risk or enhance the impacts of risk to which people are exposed to; and Protective factors mitigate the impacts of risk to which people are exposed to by preventing risk exposure or managing risk impacts.

The World Health Organisation states that in order to provide a meaningful overall assessment of systems resilience is crisis- and context-specific, it is important to employ a range of both quantitative and qualitative indicators that allow evaluation of particular aspects of systems resilience, as well as analysing experiences of other countries and different communities provides useful lessons for policy-makers implementing resilience-enhancing strategies.

The SES framework was introduced in COVINFORM as an analytical tool to understand systems, to indicate the main variables of concern in order to describe the determinants and constraints of a given system in a certain context, its resilience to rupturing events, as well as how these interact and change over time. Although first applied to the case study portion of the project, it is now being developed as a binding frame across findings in the 4 critical dimensions we are studying: governance, public health, communities, and information and communication.

Through these approaches, the COVINFORM project helps to understand how systems work and interact with each other and how their effects mitigate of enhance COVID-19 impacts on the vulnerable target populations. Thus, analysing the dynamics of all the systems involved helps to understand their degree of resilience, which in turn helps to provide a more effective response to a pandemic crisis. COVINFORM sheds light on how we can work together to protect particularly vulnerable populations and what have we learnt from this unprecedented challenge in order to make necessary changes for future world life-threatening events.

Author: Madalena Ricoca-Peixoto, Factor Social

References

Mendenhall, E. (2020). The COVID-19 syndemic is not global: context matters. Lancet, 396(10264).

McGinnis, M. D., & Ostrom, E. (2014). Social-ecological system framework: initial changes and continuing challenges. Ecology and Society, 19(2).

OECD, Organisation for Economic Co-operation and Development (2022). Health expenditure. OECD Publishing, Paris.

Quinn, K. (2019). Applying an intersectional framework to understand syndemic conditions among young Black gay, bisexual, and other men who have sex with men. Social Science & Medicine.

Sangaramoorthy, T., & Benton, A. (2022). Intersectionality and syndemics: A commentary. Social Science & Medicine, 295(113783).

Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. Lancet, 389(10072), 941–950.

Kline, N. (2020). Syndemic statuses: Intersectionality and mobilizing for LGBTQ+ Latinx health equity after the Pulse shooting. Social Science & Medicine.

WHO, World Health Organisation (2020). Strengthening health systems resilience: key concepts and strategies. European Observatory on Health Systems and Policies. Regional Office for Europe.

Project outputs:

Antunes, D. Miccoli, S. & Ambrosetti, E. (2022). Socio-Economic Impacts of COVID-19. Bi-monthly report 10, July 2022. COVINFORM H2020 Project No. 101016247.

Molenaar, J. (2021). Using an intersectional lens to understand the unequal impact of the COVID-19 pandemic. Bi-monthly report 5, September 2021. COVINFORM H2020 Project No. 101016247.

Patrick, L. (2023). Let me explain: why we use intersectionality and complexity theories. Available at: https://www.covinform.eu/2023/04/18/let-me-explain-why-we-use-intersectionality-and-complexity-theories/

COVINFORM deliverables

D3.4 Case study reports and comparative report (phase 1).

D3.6 Multi-site research design and methodological framework (update).

D4.4 Synthesis and lessons learnt on governmental responses and impacts.

D5.4 Synthesis and lessons learnt on public health responses and impacts.

D6.4 Synthesis and lessons learnt on community and citizen responses and impacts.

D7.4 Synthesis and lessons learnt on communication, information and misinformation.