Epidemics, Pandemics and Syndemics — vulnerable individuals and vulnerable communities

Dr Renay Weiner, Public Health Medicine Specialist and Director Research and Training for Health and Development, Johannesburg South Africa 

South Africa’s declaration of a State of National Disaster sets us in line with the unprecedented global mobilisation of governments, public health institutions and the public in response to COVID-19. Until yesterday, confirmed local cases were limited to travellers. Efforts to contain the spread of the virus and panic were led by the Ministry of  Health in partnership with NICD, through timeous public communication, ongoing surveillance and rigorous contact tracing.  But, as announced last night, the first case of internally or local transmission is confirmed, and more are expected. 

This is surely the major threat to South Africa.  Unlike the demographic profile of the infected travellers, the context of many South Africans particularly those living in urban informal settlements is likely to promote ongoing and rapid spread within communities.  Local transmission will make the most vulnerable communities at greatest risk of high infection, transmission and mortality rates. These are also communities with less access to services and information for protection and response, and a higher proportion with compromised immune systems due to poor nutrition and other illnesses such as HIV.  At the same time, these communities tend to have low proportions of elderly populations, which could mitigate some of the impact, especially on health services.  

Key reflections and lessons learned from epidemics in the African context could not be more relevant. The 2019 book “Epidemics and the Health of African nations” * proposes a `syndemic approach’ to tackling diseases in African contexts, in which both the understanding and responses to illness expand beyond a biomedical approach. A syndemic approach recognises the key social forces and structural drivers that interact with diseases to exacerbate their progression and impact – that is, it recognises the context within which epidemics occur. 

While we are yet to see COVID-19 spread through communities and co-exist with longstanding poor nutritional status, TB and HIV, preparedness for widespread infection is critical. In the long term, addressing social factors, particularly poverty, food insecurity and unemployment, and strengthening health systems will provide the best protection to vulnerable communities – strategies that will have multiple desired health and well-being outcomes.  In the meantime, strong leadership including at local levels, will be key for the anticipated local syndemic. Improving district and metro level surveillance and quarantine capacity, as announced last night, is critical. But other immediate issues to be addressed include stigma which has already started to emerge, food supplies for families whose livelihoods may be cut off through isolation of those infected, and the supply of water and soap so that people can respond to the proposed mass communication on improved hand washing. These actions need to be taken not only by relevant government departments, but in partnership with business and civil society.  At a health systems level, the emerging role of community health workers to interface with those affected will be crucial.  Similarly, as the book highlights, lessons from successful containment of epidemics in Africa, such as Ebola in Nigeria, requires that existing services are maintained. In our context this would include HIV testing and treatment, immunisation programmes as well as TB and chronic disease management. This will help to ensure that the most vulnerable members of the most vulnerable communities are protected from severe complications of COVID 19. 

 *Epidemics and the Health of African Nations. Mazibuko Z(ed). Mapungubwe Institute for Strategic Reflection (MISTRA). Johannesburg 2019.   mistra.org.za