December 1, 2020

Covid-19: the emerging syndemic



We live in a frenzy. We consume resources quickly and dispose of tons of them, even with their packaging. We want everything instantly, cheap, the best. This requires a global industrial and commercial activity that entails the exploitation of all the natural resources of the planet, in an unsustainable way, which exposes us to new microorganisms and transmission vectors, present in the ecological niches that we invade and destroy. And here the problem begins: we are not adapted to these pathogens, neither from the immunological or evolutionary point of view, and we lack drugs and vaccines that protect us from the diseases they carry. Only between the years 2011 and 2018, the World Health Organization (WHO) acted against 1,483 epidemic events that affected 172 countries.

The speed at which we are exposed to new emerging viruses is increasing and is almost proportional to the size of our footprint on the planet. On average, every three years a new virus emerges (such as Zika, West Nile, Chikungunya, Keystone, Oropuche, or Akhmeta) and every six we experience a pandemic outbreak of a respiratory virus (such as H5N1 avian, swine or H1N1 influenza, SARS or MERS).

An emerging respiratory virus can travel with us, going in a few days from being local to spreading across the planet at the speed of a commercial flight. We are living it with the new SARS-CoV-2 coronavirus; respiratory virus that is transmitted through the air, predominantly in the form of an aerosol, the propagator par excellence being an asymptomatic person, who can be infected for weeks or months, with a high viral load.

The global society of the 21st century must assume that Science is inescapable to overcome the new challenge of emerging viruses, and bear in mind the complexity of pandemics

We must actively identify this phenotype, with scouts and tests, to limit outbreaks and, through selective quarantines, stop the community spread of the virus and avoid social collapse. A long-lasting pandemic such as Covid-19 undermines the health system, enhances morbidity and mortality from other diseases, increases the impact of other epidemics / pandemics already underway (such as HIV, tuberculosis, diabetes and other chronic diseases of our time) and weakens the economy, by targeting the most sensitive economic sectors, exacerbating the social inequality of the most vulnerable.

It is necessary to recognize that we face a syndicate

Worldwide, we already count more than 37 million people infected by SARS-CoV-2, surpassing one million deaths from the Covid-19 disease. Most governments have reacted by focusing on the monitoring of epidemic curves, with almost exclusively hospital data, and using terminology typical of a century-old plague. All our interventions are reactive, tracking to try to cut the lines of viral transmission, once an infected person has been identified. This is necessary and urgent to do it correctly, but more urgent is to anticipate the virus with scanners to identify the asymptomatic, silent transmitters and main responsible for the community spread of the virus. Action that incomprehensibly we refuse to undertake.

We must accept the fact that we are taking too narrow an approach to managing a global epidemic of a deadly new coronavirus, treating it as a transient infectious disease, manageable through expeditious actions for 15-20 days (in aid of hospitals). However, as we are experiencing, the Covid-19 pandemic is not that simple to tackle. We wonder what is wrong. By not wanting to anticipate this complex scenario, we will now have to prepare ourselves to resolve an even greater complexity, facing two categories of diseases that will interact with each other: one, the SARS-CoV-2 / Covid-19 infection itself, and two , a whole series of chronic diseases, infectious or not, that we cannot stop taking care of. The sum of one and two, in a context of social and economic disparity, exacerbates the adverse effects of each disease separately.

Only between 2011 and 2018 the World Health Organization faced a total of 1,483 epidemic events that affected 174 countries

Faced with this reality of complex synergies, the use of the term “public health epidemic” quickly becomes obsolete for Covid-19. This was already verified in the 80-90s, when the spread of HIV / AIDS in the slums of large cities was not adequately addressed, which led to the narrow transmission of HIV / AIDS along with other public health problems, such as tuberculosis, sexually transmitted diseases, hepatitis, cirrhosis, infant mortality, drug abuse, or suicide, among others. Political, economic and social factors intertwined and influenced, and sustained this complex public health problem for decades. This is how, from the hand of Merrill Singer, the concept of syndemic was born: synergy of pandemics.

Covid-19, therefore, should not be considered only as a pandemic, but as a syndemic. That is to say, it synergizes with other diseases and social issues, aggravating them and increasing the difficulty of addressing them. This concept focuses on the problem of SARS-CoV-2 / Covid-19 as a challenge to be addressed in a comprehensive way, acting on several fronts at the same time. The strategy must analyze the health consequences of interactions between diseases and the social, environmental and / or economic factors that promote such interaction and worsen the disease. We must pay close attention and help in very specific social settings, wherever the susceptibility of being afflicted with any disease increases and, therefore, the sources of infection and spread of SARS-CoV-2 and Covid-19 are favored. Recognizing that we are facing a Covid-19 syndicate implies that we must do the following:

1) Make an inventory of all the diseases and health conditions that are affected, and of population centers where help is most needed.

2) Analyze mechanisms that promote the interaction between any disease and Covid-19, to identify the patients most sensitive to Covid-19.

3) Describe, report on the socio-environmental, biological and psychological conditions that favor the impact of Covid-19 on health in general, and vice versa.

4) Assess and quantify the greater workload that our toilets will face, in hospitals and health centers, as well as in nursing homes, due to the effects of the SARS-CoV-2 infection itself, the pictures of the Covid-19 and for its syndemic effect. To face the challenge, we must strengthen our Hospitals and health centers, at all levels, from the increase in staff, the acquisition of appropriate technology and means, the application of scientific knowledge that arises during the study of this virus and disease, and adequate training of personnel. , implementation of treatments, tests and creation of centers for the study of emerging viruses (countries that seriously face these threats have these centers on their main hospital campuses, due to the importance and severity of emerging viruses for health, and their impact on the society).

5) Finally, it is necessary to anticipate the management and mobilization of funds, the investment that will be necessary to adequately face the Covid-19 syndemic. A syndemic such as Covid-19 will reduce the effectiveness of drugs and healthcare, increasing the costs of treatment in patients affected by any disease, whether or not they are infected with SARS-CoV-2.

In addition, we will have to offer specialized medical assistance to the cohort of convalescents who will suffer sequelae from the SARS-CoV-2 / Covid-19 infection, regardless of whether they have been symptomatic or not, and who will need follow-up for years. This budget must be anticipated now.

Due to the seriousness of many of the consequences of Covid-19, the United Kingdom has already established a plan of care and follow-up action for the convalescent cohort (thousands of people in each city). Logically, political confrontations, social lack of coordination, and ignoring science in decision-making, worsen the Covid-19 syndemic, and can prolong it for years. In other words, borrowing a football simile, “there is still a game to play.” Therefore, we must be active in identifying asymptomatic people infected by SARS-CoV-2 in the population, by economic sector, structuring work teams, both to explore and locate the silent infected and to track the symptomatic infected and their contacts. We have to anticipate the virus and prevent outbreaks and sources of spread from arising, as the countries that best control this crisis have done. Sharing information, science, strategies, media and cooperating are necessary tools to combat this coronavirus.

Covid-19 must be considered a syndicate, that is, it works in conjunction with other diseases and social issues, aggravating them and increasing the difficulty of addressing them and trying to eradicate them

We should seriously consider seeking help from countries like Germany, China, New Zealand or South Korea, for example, to effectively tackle this problem. It is the way to prevent our hospitals and health facilities from being on a constant roller coaster (the so-called waves), which is going to get worse due to the tsunami associated with the infection by SARS-CoV-2 / Covid-19. Recognizing that we must confront the Covid-19 syndemic will help us understand the complexity of the challenge and tackle it with comprehensive, holistic public health actions, urgent for the reactivation of our economy.

The Age of Pandemics: The Importance of Being Prepared

Globalization, international trade, mass tourism … Our current way of living forces us to work globally and locally in a coordinated way, to face the challenges and threats associated with emerging pandemics such as Covid-19. This scenario, new for the Canary Islands, for the country and Europe, is well known to countries in Africa and East Asia that, in the last 15-20 years, have suffered pandemic outbreaks due to respiratory viruses, such as SARS, MERS and H5N1, among others. These regions are aware and prepared, successfully facing SARS-CoV-2 and Covid-19. The joint institutional and private sector effort must be firm, and finance research and specialized industry, in all necessary areas. Fundamental research is crucial to deciphering what these viruses and the diseases they cause look like, designing drugs, vaccines, and public health strategies to combat them. Our hospitals must be world-class, just like the primary care network.

The global society of the 21st century must assume that Science is unavoidable to adapt and overcome the new challenge of emerging viruses, and bear in mind the complexity of pandemics that have a great impact on patients and the economy; society as a whole. We are in the era of pandemics, we must be prepared to turn the challenge into development opportunities for our islands and society.

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