Beyond the pandemic. The concept of syndemics and aspects of anthropology in medicine.

We simultaneously form part of multiple systems: every decision and choice we make has repercussions on the lives of other living beings and triggers changes in one or more of the environments we inhabit (economic, natural, social, health, etc.). For some time now, we have believed that our lives were being stricken by a pandemic, i.e. by a factor that was increasingly mysteriously invading the world’s population, overturning the rationalization of the world we all believed in until then.

On September 26^th, 2020, Richard Horton – Editor-in-Chief of the medical journal The Lancet – issued a warning: “COVID-19 is not a pandemic. It is a syndemic. The syndemic nature of the threat we face means that a more nuanced approach is needed if we are to protect the health of our communities.”

The English neologism syndemic (a portmanteau word, from ‘synergistic’ and ‘epidemic’) was coined in 1990 by the medical anthropologist Merrill Singer, to define the biological and social interactions between communicable and non-communicable diseases (and to determine the prognosis for both). As noted in the Treccani Encyclopedia in its comment on this neologism, ‘demos’ (δῆμος) is the people, ‘epidemic’ (ἐπί~) is “above the people, within the people", and ‘pandemic’ is “in all the people”. In turn, ‘syndemic’ (σύν~) means “together with the people". All together, we were immersed in a condition of pathology and fear, further – if unwittingly – fed on by unfavorable conditions created by humankind ourselves and the errors we made in long-term forecasting on choices that could have seemed the best ones to make. Since then, these choices have proved to be systematic failures.

Once again, the issue is complexity, a concept we all attempt to deal with using a variety of tools. By its nature, however, complexity requires acceptance that some things are inaccessible. Back in 2006, Henry Jenkins set rules for the convergent culture that has come about and burgeoned online, connecting and mutually conditioning every one of us, especially in terms of the media.

The last two years have resulted in a convergence of both opinions (with all the positive and negative effects related to this mashup of information), and of suffering. Again, Treccani recalls that this convergence could be referred to in Greek as ‘sympathy’ (σύνπάϑεια), although as Simonetta Pagliani noted on Scienzainrete.it in November 2020, it would have made the hair stand on end to consider COVID-19 as anything pleasant. Even so, sympathy is also a means of increasing knowledge and raising awareness of our relationships with each other. First and foremost, a syndemic is an anthropological concept, uniting our notion of culture in the world and between us all to how we survive and care, for ourselves and for the systems we inhabit.

Alongside Emily Mendenhall and other contributors, Singer explained in another issue of The Lancet back in 2017 that: “A syndemic approach provides a very different orientation to clinical medicine and public health by showing how an integrated approach to understanding and treating diseases can be far more successful than simply controlling epidemic disease or treating individual patients.”

An integrated approach considers many aspects: social justice, access to care, levels of pollution, mental health, nutrition, but also the quality of care environments, the options to manage the emergency, balancing procedures and flexibility. The need to take action on several levels is acknowledged by the scientific community, but consensus cannot always be reached on how to improve these conditions.

Although intended positively, many paradoxes remain in the disruption of a system no longer suitable for developments in human health and the environment in which we live. The first of these is the presumption that complexity can be overcome with the assistance of useful yet insufficient tools, based on the knowledge that – as humans – our lives are finite.

Artificial intelligence will boost our potential, but it must be used a tool to raise awareness of the limits of our actions as imposed by nature. We must remember that while nature often appears to us to be acting irrationally, rationale and logic nourish human development around the world, but also serve as a trap. In the knowledge that the fight against non-communicable diseases (NCD) is a prerequisite to contain further waves of COVID-19 (as outlined in The Lancet’s publication of the NCD Countdown 2030), the roots of chronic diseases need to be explored in a multidisciplinary manner, in an expansion of the concept of care. Paraphrasing Horton: if we do not understand this and treat COVID-19 as a mere biological event, there is a risk of much more dangerous diseases in the future, never mind the fact we will be unaware how they came about.

According to the medical anthropologist Stefania Consigliere – author of several books on the relations between disease and environment, and organizer of two editions of a Master's course on Ethnomedicine and Ethnopsychiatry – attention must be paid to the toxic splinters ensconced in the imagination. Fear clearly constitutes one of these splinters; these days, the perceived proximity of war can only be counterproductive as regards empowerment, the feeling of control over ourselves, our health and our future, all of which are prerequisites to reduce the impact of viruses that by definition elude the tools currently used for forecasting.

Confusion and dismay arise from a veil being drawn over the possibility that human beings can control natural events, on top of the impression of the inability to control history. We have developed and adapted to change, by constructing stories that empowered us over the air, water, earth, and other non-human living beings. However, we are constantly attempting to gain greater (more personal) power over the psychic, affective, cognitive context, which also consists of myths, dreams, and metahistorical boundaries between what is and is not permissible. The background to the workings of the virus is polluted by improper nutrition, stress, fine particles, and melodramatic scenarios.

But there is also another pollutant we lack the courage to consider, which Horton deigned to identify: the lack of hope. The fact that the feeling of hope is the real panacea has been verified by several studies on longevity. Our awareness is fundamental, but it is useless if our imagination becomes a closed system, where we believe everything can be predicted. Such a scenario therefore excludes unexpected solutions, especially in seemingly desperate situations. Doctors, even more so than medicine itself, have always been considered bearers of hope in desperate situations: part of their work involves creative, impromptu solutions, outside the predictive box.

In turn, these solutions foreshadow scientific progress. When they can listen to patients, using tools that help them to focus their attention on the essentials, doctors can bring hope by reconstructing complex pictures and personalizing care, which mitigates the creeping poison of fear.

The pandemic has resulted in an upheaval of the rational, whereas the concept of a syndemic can teach us to broaden our horizons to the invisible lines connecting everything there is.