Proceedings of a Workshop

Using Syndemic Theory and the Societal Lens to Inform Resilient Recovery from COVID-19

Toward a Post-Pandemic World

Proceedings of a Workshop—in Brief

On March 17, 2021, the Forum on Microbial Threats of the National Academies of Sciences, Engineering, and Medicine’s (the National Academies’) Health and Medicine Division hosted a virtual workshop on considering COVID-19 through a syndemic approach (analyzing the health consequences and interactions of multiple epidemics within a population in combination with underlying social, environmental, and economic drivers) and the implications that perspective might have for the ongoing response efforts in the United States and around the world. In addition, the meeting sought to raise prospective ideas for enhancing resilience and preparedness for future outbreaks.

This event kicked off the forum’s initiative to evaluate lessons learned from the pandemic and served as a framing workshop for thinking about its long-term, cross-sectoral, and global impacts. Speakers and panelists addressed (1) the biological and social determinants of health that are involved in identifying and describing syndemics; (2) the reasons for and implications of using the syndemic framing for COVID-19, based on the influence of particular geographic and community contexts on localized disease impacts; and (3) why thinking about COVID-19 and other disease outbreaks through a syndemic lens is important for public health officials and the general public.

This Proceedings of a Workshop—in Brief summarizes the presentations and discussions that occurred at the workshop. A broad range of perspectives were shared during the event.

INTRODUCTION

Elizabeth Hermsen, head of global antimicrobial stewardship and health equity in infectious diseases at Merck & Co., Inc., introduced herself and Rafael Obregón, Paraguay country representative for UNICEF. She opened the workshop with brief welcoming remarks and acknowledgments. Hermsen summed up the goal of the workshop: elucidate the multifactorial nature of COVID-19 by considering its syndemic nature as a way to start identifying cross-sectoral areas of concern. She contextualized the workshop by explaining its intent to evaluate the broader impacts on human health and global development, critically examining what responses have and have not been effective worldwide, with an eye toward informing resilient recovery and better preparedness for outbreaks.

KEYNOTE

Defining a Syndemic

Laura Helmuth, editor in chief of Scientific American, moderated the workshop. She offered a condensed definition of a syndemic as a “powerful concept that tries to capture the fact that a pandemic isn’t just about the characteristics of the virus, but [also] the ecosystem into which the virus is spreading.” The syndemic approach to understanding public health events, she explained, recognizes that the dynamics of an outbreak are shaped and amplified by social, biologi-

cal, and even political factors, including systemic racism, preexisting health disparities, xenophobia, and misinformation. Emily Mendenhall, the Provost’s Distinguished Associate Professor in Science, Technology, and International Affairs at the Georgetown University Edmund A. Walsh School of Foreign Service, gave the keynote address that discussed (1) what a syndemic is, (2) what syndemic thinking can accomplish, and (3) how this all applies to the current situation regarding COVID-19. She defined a syndemic as “a dynamic relationship involving two or more epidemics and the social factors that precipitate their interaction within a population.”

Mendenhall presented three steps to identify a syndemic that boil down to “clustering, interactions, and drivers,” as modeled by Merrill Singer, who pioneered syndemic theory in the 1990s (Singer et al., 2017). The first is recognizing co-clustering of disease states. This relies on epidemiological studies of comorbidities or multi-morbidities. Once clustered disease states are identified and localized, the second step is recognizing critical adverse interactions at the levels of biology, psychology, and social relationships (e.g., social stigma that discourages patients with diabetes from seeking care for fear of being suspected HIV positive, thereby worsening local disease outcomes for not only HIV but also diabetes). The final step is identifying structural and social drivers that precipitate disease clustering (e.g., systemic racism or historical trauma).

At its core, syndemic theory is concerned with how critical structures and experiential dimensions affect how people get sick, where they get sick, and why they get sick. Mendenhall stated that a syndemic lens is a way to translate principles from anthropology across disciplines and operationalize them to create and implement effective public health interventions—at not just the clinical level but the policy level, and perhaps even farther upstream.

One of the critiques of syndemic theory, Mendenhall explained, is that identifying and measuring social-level interactions can be complicated compared to more familiar public health research models. She elaborated, however, on how the committed study of syndemic theory has generated new metrics, methodologies, and several important research questions¹ at the intersection of social science and medicine (e.g., how can researchers measure the impact of certain policies regarding sweeteners in beverages on clustered disease outcomes, such as obesity and diabetes). An example of an early study that took on a complicated syndemic question was conducted by Singer himself in 1996; it examined interactions among HIV, violence, and substance abuse (Singer and Hispanic Health Council, 1996). The key takeaway for Mendenhall was that, in the population of inner-city Hartford, Connecticut, an actionable and comprehensive understanding of HIV—including its outcomes and drivers and the lived experiences of those with HIV—is impossible without an equivalent understanding of substance abuse and violence in that same population. Any effective intervention, Mendenhall stated, would have to account for the deep interconnectedness of those three epidemiological phenomena’s experiential impacts.

In her own research² to understand the disease-exacerbating cofactors in a population of Mexican American women with type 2 diabetes, Mendenhall found pervasive accounts of social isolation and feelings of ostracism; past and ongoing physical, emotional, and sexual trauma; and persistent fear, depression, and anxiety.

In a follow-up 3 years later, Mendenhall found that mental health interventions could profoundly improve overall disease outcomes. In one case, she assisted an interviewee with severe depression in accessing mental health care. After an extensive process of finding affordable, Spanish-language, local psychological treatment, the woman was able to not only process her extraordinary trauma but also escape her abusive home environment, find employment, and get her depression and diabetes under control. Mendenhall argued that based on this example that a sense of social belonging and recovery from trauma can dramatically improve syndemic suffering.

The Value of the Syndemic Framework

The real value in the syndemic model, Mendenhall explained, lies in how it can change the ways we think about, measure, and respond to disease. Syndemic thinking is cross-disciplinary, actionable, and able to avoid oversimplifying conceptions of disease. It lays the groundwork for integrated, people-centered clinical care and community-based interventions that can mitigate disease interactions. Mendenhall proposed the following transdisciplinary agenda for better integrating a syndemic-based philosophy into health:

1. Changing how people think about disease.
2. Bringing together multiple fields of inquiry.
3. Cultivating a comprehensive view of syndemics.
4. Working from ethnography to epidemiology to provide evidence for needed tools.
5. Developing methods to identify and test syndemic concentrations and interactions.

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¹ For examples, see Himmelgreen et al. (2020) and Weaver and Kaiser (2020).

² See Mendenhall (2012).

6. Raising awareness about and developing methods to incorporate biological, psychological, and social interactions in quantitative analysis.

Mendenhall laid out several possible social remedies for drivers of worsened disease states in the United States: better nutritional labeling and education; improved school lunch options and access; and expanding access to affordable housing, health care, and legal counsel, especially in a clinical setting. She also proposed ways to rethink clinical care, such as person-centered medical homes, which can better coordinate treatment for co-occurring conditions; offering incentives for general practitioners to keep their patients healthy and comprehensively consider their well-being; expanding clinical care teams to include not only more nurses and technicians but also social workers, lawyers, mental health experts, and team coordinators; and improving home visits to treat “super-utilizers”³ who are underserved by fragmented specialty health care.

In addition, Mendenhall emphasized the need for downstream community-based interventions, such as community mental health services, improved access to translation services, community health education efforts, and easy access to health counseling. Ultimately, she asserted, effective health care involves meeting individuals where they are and not requiring them to seek care on their own. Mendenhall highlighted how creating spaces such as peer group counseling sessions can be impactful: patients can find others with shared identities, talk about their experiences, and offer one another assistance on everything from health resources to financial literacy.

COVID-19 as a Syndemic

For the ongoing COVID-19 pandemic, Mendenhall reiterated that the nature of a syndemic implies highly localized factors. While COVID-19 has had a worldwide impact, context has a profound effect on an individual’s or population’s experience of it and, in her opinion, COVID-19 cannot be addressed in a single meaningful way on a global scale.

Using the United States as an example, Mendenhall explained that historical, ongoing, and systemic inequities, racism, and violence are critical in determining who gets sick, why they get sick, and their outcomes (Gravlee, 2020). Sociopolitical contexts and historical forces, especially for COVID-19, drive disease clustering. By nature of this, Mendenhall asserted, political leadership plays a huge role in the public perception of risk and the behavior that such perception drives. The example she offered that highlights this critical value of leadership was a rural Iowa town, where the population has not responded well to political messaging or demonstrated a sense of closeness to or trust in their state or national leaders (Koon et al., 2021; Mendenhall, 2020). The community has been unreceptive to taking up behavioral best practices suggested by public health authorities and has thereby suffered disproportionately. By contrast, Mendenhall’s colleagues in Rwanda have seen strong social cohesion and trust in leadership, associated with a relatively low infection rate and high levels of community cooperation.⁴

Mendenhall discussed the strategies and pitfalls in building baseline community health and cohesion. A close-knit community is often a healthier one, but COVID-19 has shown that some isolated or ideological social networks can also rapidly spread dangerous misinformation about health. In attempting to address this, she proposed amplification of accurate information, coherent messaging from leadership, and opportunities for communities to de-isolate as ways to help.

Mendenhall closed with some examples for empowering communities to follow a path of collective ownership, empowerment, and self-determination in improving baseline well-being. Each community’s health is, like a syndemic, highly context dependent, so effective solutions can often only come from within. She said that providing communities with the resources to take initiative and improve their own well-being is essential.

PANEL DISCUSSION

Syndemic Patterns in the COVID-19 Experience

Jeffery Duchin, health officer and chief of the Communicable Disease, Epidemiology, and Immunization Section for Public Health (Seattle and King County, Washington),⁵ and Marcos Espinal, director of the Department of Communicable Diseases and Environmental Determinants of Health at the Pan American Health Organization (PAHO),⁶ joined Mendenhall for a panel discussion.

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³ For more information on these and possible treatment models, see Lantz (2020).

⁴ For more information on the social aspects of Rwanda’s COVID-19 response, see an interview with the former health minister at https://www.bmj.com/content/371/bmj.m4720 (accessed April 29, 2021).

⁵ Duchin was one of the first U.S. public health officials to face COVID-19 infections and deaths in February 2020.

⁶ Espinal served as a public health officer at the Dominican Republic Ministry of Public Health and Social Assistance and the New York City Department of Health and Mental Hygiene.

Helmuth opened by inviting Duchin and Espinal to share their experiences of responding to COVID-19 in the public health arena. She asked them how Mendenhall’s description of the global-yet-local syndemic nature of COVID-19 resonated with their lived experiences of it.

Duchin gave a brief overview of disease dynamics from his perspective. The first wave began in Seattle and King County in February 2020 in long-term care facilities. Most of the morbidity and mortality took place in the primarily white, elderly residents and the primarily Black, Indigenous, and people of color (BIPOC) who staffed the facilities. The second wave came over the summer, as in most of the rest of the United States, with predominant transmission among younger adults. A large third wave followed in fall and winter 2020, which was responsible for about two-thirds of the county’s hospitalizations and deaths. The outbreak evolved to disproportionately impact the case, hospitalization, and death rates of African Americans, Hispanic Americans, Native Hawaiians, Pacific Islanders, American Indians, and Alaska Natives.

Duchin continued by describing how early preconceptions that COVID-19 was transmitted primarily by symptomatic individuals via respiratory droplets gave way to realizations about asymptomatic and aerosol airborne transmission. New revelations also came quickly when considering social dimensions. Eventually, Duchin said, Seattle and King County case, hospitalization, and death rates revealed patterns of health disparity similar to those in underlying conditions and chronic diseases. Life expectancy in the county varies by up to 18 years between certain neighborhoods. Indicators of poor health, such as poor housing conditions, tobacco use, frequent mental distress, adverse childhood experiences, diabetes, preventable hospitalizations, lack of physical activity, and obesity, are all correlated with lower household income and lack of educational opportunity—which, in turn, disproportionately impact BIPOC communities, Duchin explained.

The syndemic model, Duchin explained, applies strongly to Seattle and King County, with regard to both its baseline health disparities and the overlay of the local COVID-19 epidemic. One of the main challenges in applying the syndemic model, however, lies in the currently poor understanding of the pathophysiology and biological sequelae of COVID-19. Such knowledge, said Duchin, will be fundamental in understanding how the disease interacts with others, regardless of the clear social cofactors of socioeconomic inequality and systemic racism.

Espinal discussed Brazil as an example of how considering COVID-19 as a syndemic is context dependent. At the outset of Brazil’s outbreak, Espinal encountered sweeping generalizations about Brazil as a whole; he argued that this attitude ignored huge variabilities, with some communities having no cases and some (especially Indigenous groups in Manaus, which suffered some of the highest mortality rates in the world) being severely impacted (Ferrante et al., 2020).

A Broader Lens on Intervention

Espinal pointed out that one of PAHO’s main concerns is ensuring that conversations about the pandemic extend beyond considering it merely a public health problem and instead address it as an economic and social problem as well.

Espinal drew a parallel between particular syndemic considerations for tuberculosis (TB) and COVID-19. TB, he explained, is often perceived as a “disease of the poor,” long associated with overcrowded and unsanitary living conditions. Espinal said progress in TB control in recent decades has been closely associated with socioeconomic development and improved living conditions. Similarly, one of the behavioral fixtures of the COVID-19 response has been social distancing, which Espinal pointed out has been framed as a concept mostly for the wealthy and privileged.⁷ He argued that when a community does not have access to non-shared housing in which to isolate, clean water with which to wash their hands, or face masks with which to protect themselves and others, many of the behavioral interventions commonly recommended for COVID-19 and other communicable respiratory diseases, such as pulmonary TB, are simply nonstarters. In Latin America, Espinal explained, countries are growing economically, but wealth gaps in those countries are also growing. He outlined how PAHO has been advising countries to couple their health interventions with social and economic measures.

Translating Syndemic Strategies to COVID-19 Response

Helmuth asked the panelists about effective interventions for syndemics associated with TB, diabetes, or HIV/AIDS that might translate well to responding to COVID-19. Espinal believed that the most important category of intervention was community engagement. He suggested that when national and local authorities partner with communities, results are seen faster than if outsiders alone impose exogenous health strategies on a community. He offered intersectoral collaboration, teamwork, and empowerment as key words for effective intervention.

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⁷ For examples of this framing, see Nossiter (2020) and Paredes (2020).

Duchin added to Espinal’s comments by explaining how underlying structural issues and inequities do not draw the requisite attention during “peacetime.” During any public health disaster, in Duchin’s experience, such glaring disparities are brought to the fore and instigate a resounding public cry to respond accordingly. However, underlying issues that predispose certain populations to disproportionate suffering in times of crisis are not caused by the crisis itself; they are, he argued, long-standing, structural problems that cannot be quickly rectified, and they are likely to require a fundamental reevaluation of health equity and long-term investment. Duchin elaborated that this is complicated by recognizing that communities at the highest risk of COVID-19 often comprise a large portion of essential workers and include job types disproportionately held by BIPOC and individuals of lower socioeconomic status. These communities, in Duchin’s experience, may harbor fundamental distrust and skepticism of government and the health care system.

Expanding on Espinal’s discussion of social distancing as a privileged public health intervention, Duchin explained how people in multigenerational households often have less space, live in areas with higher population densities, work mandatory in-person jobs more often, and have a more critical need to work based on their incomes and the hourly wage nature of many of their employment opportunities. Well-resourced communities, he argued, have the luxury of taking substantially better precautions to prevent the spread of COVID-19. These problems cannot, according to Duchin, be addressed during a public health crisis; trust, investment, and infrastructure all take a long time to build.

Duchin added two other health impacts from the pandemic he witnessed that are distinct from the disease itself. Seattle and King County have seen de-intensification of homeless shelters due to the outbreak, which may have contributed to (though the evidence remains anecdotal) upticks in gastrointestinal infections and opioid overdoses (especially those involving fentanyl).

Community Health Models

In a discussion about meeting patients where they are with the care they need, Mendenhall offered her own health care experiences in Washington, DC, and the United Kingdom to demonstrate the efficacy and possibility of better health care delivery. House calls and therapy delivery, she posited, need not be rarities. All three panelists argued that by harnessing the urgency and new mobile health technologies that COVID-19 has introduced, such outreach can be incorporated into routine health care. Duchin offered the example of the Nurse–Family Partnership⁸ as a working model currently in action around the United States.

Despite the value of community health worker models in treating chronic conditions, diabetes, mental health, and other illnesses, Duchin pointed out that funding is a persistent issue for providers, who often have difficulty seeking reimbursement for particular services (e.g., home visits and behavioral health). Espinal responded, using Costa Rica as a case example, that the reimbursement problem can be resolved by a universal health care system. This type of system, he explained, is contingent upon confidence in health care workers and a proportionally large workforce, but Costa Rica was able to provide regular home visits for COVID-19 patients and keep those who were not severely ill out of crowded hospital settings.

COVID-19 and Misinformation

Espinal discussed misinformation during the COVID-19 crisis. He emphasized that combating misinformation regarding health is a critical responsibility for national and local authorities, because in a vacuum of effective public messaging during a crisis, falsehoods fill the gap. This problem, Espinal explained, is not just affecting the United States; nations in Latin America (especially those with low literacy rates) also struggle with misinformation. Helmuth added that one consistent finding with misinformation interventions is that personal relationships make an enormous difference in communicating the truth. She entreated the audience to, with compassion, call out and correct misinformation that they might encounter in their daily lives.

Looking to the Past and Learning for the Future

Helmuth asked the panelists if they felt that COVID-19 represented an opportunity to garner the attention needed to address the syndemic underpinnings of the pandemic, future crises, and ongoing health inequity. Duchin began by explaining that the history of public health is plagued by episodic post-crisis investments followed by rapid regression to previous levels of underfunding. Programs, staff, and resources come and go quite frequently, taking a toll on the sense of community in the field. The cycles of funding and underfunding also mean, according to Duchin, that much needed infrastructure improvements, information system capabilities, and efforts to ameliorate structural health injustice never receive the long-term attention and investment they require.

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⁸ For more information, see https://www.nursefamilypartnership.org (accessed June 2, 2021).

However, Duchin said that he is hopeful that people will learn from COVID-19 that health systems are sorely underprepared for modern public health disasters. He explained that the gaps are now obvious, but it will still require an immense mobilization of political leadership at the highest levels to ensure public health systems are prepared and investment in the well-being and health equity of communities is taken seriously. Espinal shared the hope that public health systems can change from a reactive to a proactive model. He cited the promise shown by the World Health Assembly reviewing its International Health Regulations (IHR)⁹ and the G7 discussing One Health.¹⁰

One major issue with the current system of global health governance, Espinal explained, is that it is entirely voluntary. Emergent diseases, he said, know no borders, so cooperation must be fostered by both enforcing accountability and being more generous with resources. He said he envisioned a future with more proactive disease monitoring and surveillance systems, new virtual tools allowing for real-time data analysis, and rapidly mobilized global responses to outbreaks.

Duchin cautioned about looking to the future too soon, because COVID-19 still poses a very serious threat, especially considering the ongoing emergence of new variants. Much more remains to be learned, he explained.

Mendenhall offered an “overarching lesson for public health [professionals and clinicians]: politics matter.” She explained that few scientists and health care experts want to involve themselves in politics, but COVID-19 has shown illness and whom it affects to be a political issue. This manifests at the global (e.g., differential conformity to IHR), national (e.g., participation in the Global Health Security Agenda [GHSA]¹¹), and local (e.g., municipal health regulations and interventions) levels. In addition, policies that deal with issues such as childhood development, poverty, and racial justice are, through a syndemic lens, matters of health security.

Duchin added to Mendenhall’s point, acknowledging how the 2019 Global Health Security Index found that, while top ranked for preparedness overall, the United States scored near the bottom of its economic peer group in categories such as access to health care, social support, and public confidence in government leadership (Nuzzo et al., 2020).¹² He added that Seattle and King County’s relatively low morbidity and mortality rates compared to other U.S. metropolitan areas may be due in part to strong and coordinated local leadership and social support programs.

PUBLIC QUESTION AND ANSWER SESSION

Racism and COVID-19

Helmuth opened the session with a question about whether new rises in anti-Asian rhetoric and xenophobia associated with COVID-19 may have played a role in American syndemics. Mendenhall pointed out that accurate data are still lacking, but she theorized based on historical trends and other syndemics she studied that the stigma arising from this type of shame-imbued racism can have a large impact on patients’ hesitancy to report symptoms or seek treatment.

Duchin added that early data from outreach efforts among Seattle and King County’s large Asian American population suggest social stigma surrounding a COVID-19 diagnosis might make Asian Americans in that area less likely to seek testing. In addition, he cited documented instances of physical and verbal violence that are likely, combined with implications for employment, to discourage Asian Americans from seeking testing or care for symptoms characteristic of COVID-19.

Espinal added the example of Brazil as a nation that has experienced multiple infection spikes and waves of mortality in part due to social stigma and racial disparities.¹³ Because of leadership’s hesitancy to recognize the danger posed by COVID-19 and the associated dearth of coordinated public health responses, Espinal explained, it is especially difficult for historically deprived communities of Afro-Brazilians and Indigenous people to seek the help they need for the disproportionate damage they have suffered.

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⁹ For more information on IHR, see https://www.who.int/health-topics/international-health-regulations#tab=tab_1 (accessed June 2, 2021). To read more about the World Health Organization’s review of IHR, see VOA News (2020). To learn more about the proposed pandemic treaty to strengthen IHR, see Ravelo (2021).

¹⁰ The U.S. Centers for Disease Control and Prevention defines One Health as “an approach that recognizes that the health of people is closely connected with the health of animals and our shared environment” (NCEZID, 2018). To learn more about the World Health Organization’s plans to strengthen a One Health pandemic-prevention approach, see WHO (2021). The National Academies’ Forum on Microbial Threats hosted a workshop in 2021 on this topic, titled Systematizing the One Health Approach in Preparedness and Response Efforts for Infectious Disease Outbreaks. See https://www.nationalacademies.org/event/02-25-2020/systematizing-the-one-health-approach-in-preparedness-and-response-efforts-for-infectious-disease-outbreaks-a-workshop (accessed June 2, 2021).

¹¹ For more information on the Global Health Security Agenda, see https://ghsagenda.org (accessed June 2, 2021).

¹² For more information about the U.S. scores on the Global Health Security Index, see https://www.ghsindex.org/country/united-states (accessed June 2, 2021).

¹³ For more information about health disparities and COVID-19 in Brazil, see de Oliveira et al. (2020), de Souza Santos et al. (2020), and Martins-Filho et al. (2021).

Comparing Responses Internationally

Helmuth shared a question from the audience about key aspects of New Zealand’s COVID-19 response that might apply to the United States or inform future preparedness efforts.¹⁴

Mendenhall responded that during a public health crisis, what is needed most is collective action—especially a coherent nationwide response strategy. She pointed out that the positive public perception of political leadership in New Zealand resulted in a trust capital that could be leveraged to implement strong public cooperation and epidemiological interventions, such as border closures, intensive contact tracing, and strict lockdowns. While this might not be directly translatable to the U.S. context due to culturally ingrained individualist attitudes, Mendenhall explained, the value of trust in leadership is a pertinent lesson from New Zealand’s response.

Duchin elaborated on Mendenhall’s point by adding that beyond mere initiative to cooperate in a time of crisis, jurisdictions also need access to resources to facilitate that cooperation and compliance with public health recommendations. He explained that if, for example, the national response strategy recommends home quarantine and self-isolation, then providing adequate space for those with no homes or overcrowded homes to comply becomes important. Additionally, Duchin explained, it is difficult for states to enforce the recommended stay-at-home orders if they cannot also provide emergency income assistance to those unable to work, which indicates that the problem is twofold—lack of both cooperative initiative and the needed facilitating resources.

Occupational Health Considerations

Helmuth posed a question from the audience about occupation and type of work as contributing social syndemic factors related to COVID-19 and whether solutions might exist to mitigate their effects. Duchin responded that in his experience, certain occupational groups where workers spend prolonged periods indoors in close contact (e.g., in the agricultural processing and manufacturing industries) are at higher risk for morbidity and mortality. These jobs also tend to be disproportionately low wage and disproportionately staffed by BIPOC workers. Such individuals’ higher risk at work translates to heightened risk for their entire communities, he said, especially because such communities are more likely to contain higher population densities and more multigenerational households.

Espinal added that the engineering and infrastructure implications for occupational health hazards and living condition health hazards are linked. The engineers and architects of the near future will need to reassess how workplaces, affordable housing, and prisons can improve on their environmental and health impacts, making it safer for people to spend time indoors.

Mendenhall added that occupational considerations also play a role in vaccine equity. Certain occupations, such as health care worker and educator, may be priority groups for immunization, but making such determinations and distributing vaccines accordingly pose complex challenges.

Spirituality as a Syndemic Factor

Helmuth shared an audience question about spirituality. She asked the panelists what roles religious groups and community spirituality might play in addressing some of the syndemic factors of the COVID-19 response. Mendenhall and Duchin both asserted that religious leaders can be strong promotional voices but also strong obstructive voices. Religious communities, they explained, can be powerful spaces to instill good health practices but can also become echo chambers for misinformation—especially in the United States, where Mendenhall and Duchin believe that politics, messaging, and social values are so deeply entwined with faith. Overall, Mendenhall and Duchin agreed that faith leaders will need to be partners in any effective public health strategy, because they have unique trust from and access to communities around the country.

Engaging Scientists and Policy Makers on Pandemic Preparedness

Based on several audience questions about political engagement and funding for public health, Helmuth asked the panelists whether they had any suggestions on how policy makers and legislators might be encouraged to comprehend the long-term need for investment at multiple levels to prevent future syndemics, in order to ameliorate the boom-and-bust cycle of public health funding based on how perceived risk changes over time. Additionally, she asked if the panelists might have any advice on how to engage politicians better in public health awareness and public health experts better in political awareness.

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¹⁴ New Zealand employed a relatively strong early response, and it has reported relatively low case and mortality burdens throughout the pandemic (Cousins, 2020; JHU, 2021). While a small population and geographic isolation make New Zealand somewhat unique in comparison to other high-income countries, it has been studied as a case example for evaluating the effectiveness of non-pharmaceutical public health interventions (Jefferies et al., 2020).

Espinal responded by explaining how funding for public health in Latin America is difficult to maintain because elected officials and administrations cycle out every few years.¹⁵ It is easy, he elaborated, to justify spending on visible and tangible things, such as defense and building projects, but effective public health is often invisible—it is defined by the events (i.e., outbreaks) that do not occur thanks to successful prevention measures. The argument must be made, Espinal claimed, that healthy people make healthy, productive, and wealthy nations; this is where compelling numbers can be harnessed to demonstrate value. Espinal added that such advocacy for health need not be limited to within a nation’s borders; because diseases do not respect borders, public health efforts and funding should not be constrained by them.

Duchin added that because elected officials are chosen by and reflect the values of societies, change ought to start at the community level. Increasing the value placed on health literacy and education, he claimed, could improve collective understanding of the economics and the social determinants of health and, in turn, could shift community priorities such that the decision makers elected by those communities share those understandings and priorities. He explained that lawmakers are incentivized to accomplish things quickly and concretely so they can make a compelling argument for reelection to their constituents; public health, whose perceived benefits can be difficult to visualize and often appear much later, does not fit this value framework.

Mendenhall continued by pointing out that U.S. public health is ultimately a county- or state-level responsibility. While its context-dependent nature indeed necessitates local administration, Mendenhall believes that the federal government could do more in terms of funding, standards, and emergency support to better facilitate local public health authorities’ effectiveness. Mendenhall explained that this state of affairs reflects cultural values. Health is not perceived the same way that—for example—education is; if it were, public health might be administered via a system of local authority with national-level support more similar to public education.

A COVID-19 After-Action Report

Helmuth raised another audience question about the value and feasibility of pursuing an after-action report for the U.S. COVID-19 response. Duchin responded that he considered such a report not only possible but necessary and inevitable. Reports are under way at all levels of government examining issues ranging from medical supply chains to social determinants of health to underlying health system vulnerabilities. The concern, Duchin elaborated, is not whether these reports will be published but whether meaningful action will follow. Many of the gaps identified by COVID-19 after-action reports are likely to be the same as those already identified by after-action reports for events such as the 2009 H1N1 outbreak, he said.

Pandemic Preparedness and National Security

Helmuth continued the Q&A by positing how, through a syndemic lens, public health might also be considered a matter of national security or defense. As the funds available in the United States for defense have historically been quite large, she asked the panelists if they saw value in using the syndemic lens to make a case for public health as a matter of national security.

Mendenhall responded that to a certain extent, with regard to topics such as biological threats and GHSA, public health has already been securitized. For crisis response, she believes syndemic understandings of outbreaks can provide a good scientific basis for the need to allocate funds for emergency public health preparedness. However, public health consists of more than simply preparing for the next pandemic. Because national security is, by definition, a national-level responsibility, she explained that the traditional conception of the syndemic as a community-level phenomenon makes it perhaps less effective at arguing for national security priorities. Securitizing public health, she added, also tempts narrowing it to focus primarily on biological threats and pandemic preparedness, which would detract from the horizontal health integration and community-based approaches propounded by the syndemic philosophy.

Espinal expanded on Mendenhall’s answer by offering an international perspective on IHR core capacity building, where funds are often allocated vertically to national-level health security issues instead of to community-level health systems. This, he explained, has the effect of centralizing health care resources when they ought to be much more distributed, such that people can access the services they need without traveling long distances.

Visions for the Future of Public Health

Helmuth asked a final question regarding what sorts of changes to the public health system informed by syndemic thinking the panel hopes to see in a post-COVID-19 future, should it ever arise. Duchin said he wants to see a more

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¹⁵ For more information on PAHO’s policies and goals on health care spending and financing, see PAHO (2017).

holistic approach to health overall, encompassing physical, mental, and social dimensions. He also highlighted the importance of eliminating health disparities and improving health literacy and explained that simple, effective communication and dialogue between the public and policy makers will be key to improving public health systems.

Mendenhall offered the hope that funding and research shifts from its present outcome-centric focus to a more driver-centric one. Certain diseases, such as HIV, generate a lot of interest and therefore money, which she believes creates positive feedback loops of highly focused, vertically funded, and specialized research. In Mendenhall’s opinion, using a syndemic approach can shift the narrative to consider interventions outside the typical disciplinary silos encountered in public health systems, clinical medicine, and biomedical research. She included mental health counseling, community improvement projects, food and agriculture, and environmental policy as avenues for taking a more holistic, preventative approach to health instead of the dominant pharmaceutical- and therapy-based reactive treatment models.

CLOSING

Obregón provided closing comments. In sharing his most important takeaways, he highlighted that the real value of the syndemic approach lies in how it can change the way decision makers think about disease. He explained how it promotes a multidisciplinary strategy for health that accounts for socioeconomic realities and disparities. Additionally, he emphasized the opportunity the syndemic framework offers to broaden perspectives on health to include the socioecological and environmental issues that have been highlighted by the pandemic in many nations.

Obregón pointed out that all of the presenters spoke of the importance of community engagement and community-based health solutions and the need for greater investment in such low-cost interventions. In his opinion, excessive vertical integration of public health can often overlook individuals’ holistic experience of life and health, thereby posing serious challenges to diagnostics, point-of-care accessibility, and interventions. Additionally, he argued that the “panic-then-forget” attitude toward public health crises must be broken, and resources and political will can be leveraged to transform the current tendency toward episodic interest in certain emergent diseases into lasting, forward-looking, and comprehensive improvements that account for broad social determinants of health.

In conclusion, Obregón shared some insights into the forum’s planning for a future workshop titled Toward a Post-Pandemic Future: Lessons from COVID-19 for Now and the Future.¹⁶ Topics under consideration include the impact of COVID-19 on other health issues; what can be learned from organizational successes and failures worldwide; the implications of the pandemic for public health messaging and communications; how to build pandemic resilience in all sectors of society; ways to better unite science and politics in public health; and how to break the “panic-then-forget” cycle of public health disaster response. ◆◆◆

REFERENCES

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Mendenhall, E. 2012. Syndemic suffering: Social distress, depression, and diabetes among Mexican immigrant women.https://www.routledge.com/Syndemic-Suffering-Social-Distress-Depression-and-Diabetes-among-Mexican/Mendenhall/p/book/9781611321425 (accessed April 29, 2021).

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DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Charles Minicucci as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies of Sciences, Engineering, and Medicine.

The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution. The planning committee for this workshop consisted of Elizabeth Hermsen (Co-Chair), Merck & Co., Inc.; Rafael Obregón (Co-Chair), United Nations Children’s Fund; Chandy C. John, Indiana State University School of Medicine; Kent E. Kester, Sanofi Pasteur; Rima F. Khabbaz, U.S. Centers for Disease Control and Prevention; Kumanan Rasanathan, World Health Organization; Stephen J. Thomas, State University of New York, Upstate; and Matthew Zahn, Orange County Health Care Agency.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Bridget B. Kelly, Burke Kelly Consulting, and Don Eugene Detmer, University of Virginia School of Medicine. Leslie Sims, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.*

* The Reviewers information was updated after the final release.

SPONSORS: This workshop was partially supported by the American Society of Tropical Medicine and Hygiene, Burroughs Wellcome Fund, EcoHealth Alliance, Infectious Diseases Society of America, Johnson & Johnson, Merck & Co., Inc., National Institutes of Health, New Venture Fund, Sanofi Pasteur, Uniformed Services University of the Health Sciences, U.S. Agency for International Development, U.S. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, U.S. Department of Homeland Security, U.S. Department of Veterans Affairs, and U.S. Food and Drug Administration

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/03-17-2021/moving-past-covid-19-lessons-learned-from-responses-around-the-world-syndemics-webinar.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Using syndemic theory and the societal lens to inform resilient recovery from COVID-19: Toward a post-pandemic world: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26259.

Health and Medicine Division

Copyright 2021 by the National Academy of Sciences. All rights reserved.