Syndemic: falling ill from poverty


Pandemic or syndemic? That a child born in Sierra Leone has less promising health prospects than an American child of the same age is nothing new. But the fact that getting a job promotion can significantly reduce our chances of dying is less obvious.

According to a study called Whitehall conducted among British civil servants aged between 20 and 64, people who occupy the lowest level of the hierarchical ladder (couriers, doormen, etc.) have a mortality rate three times higher than those sits at the highest levels (such as administrators). Even after eliminating standard risk factors (age, smoking, diet, etc.), the mortality ratio was still 2.1.

This is what Michael Marmot, author of the study, called the “health gradient”. The concept is not new at all (the study dates back to the early 1990s) but it seems to have been completely neglected by our society. A serious thoughtlessness, which risks compromising many of the efforts made by national health systems – and international bodies – to guarantee the health of their citizens. Including the campaign to fight Covid-19.

The social conditions of an individual – not just the population in which he lives – have a decisive influence on many health factors:

  • the chances of contracting diseases;
  • -the spread of infections;
  • the effect of drugs;
  • the impact of diseases;
  • the degree of adherence to therapy;
  • the level of prevention;
  • the consequences of containment measures such as lockdown on health.

A little too much not to consider them a key factor in global and local health strategies.

Income and health

As is known, in the poorest countries life expectancy is significantly lower than that of advanced countries and the probability of falling ill is proportionately higher. Those born in Japan or Hong Kong have almost 85 years of life ahead of them, while in the Central African Republic the average does not exceed 53 years.

This disparity has many roots, starting with the different possibilities of contracting a disease. Often the poorest areas are affected by catastrophic virus epidemics that are easily kept under control elsewhere (in developing countries the measles virus still causes one million victims a year and is responsible for 44% of deaths among children under the age of 15).

But non-communicable diseases (NCDs) are also different and should be addressed specifically. A commission from the journal The Lancet has developed a special index, called NCDI Poverty, to include some specific items from the poorest countries such as snake bites, epilepsy, kidney disease and sickle cell anemia. For the world’s poorest billion people, NCDs now account for more than a third of their disease burden. By specifically intervening on these items with “feasible and economical” measures, almost five million deaths could be avoided.

The differences, however, are not limited to the economic gap between nations or macro-geographical areas. Similar considerations can be made for the different social groups within the same country.

Health and social conditions

In England, for example, being born in the poorest areas shortens a man’s life expectancy by almost ten years (eight years for women). A fact that is not surprising if we consider how the state of health varies in relation to social conditions. In the United States, the prevalence of obesity among adult women is inversely proportional to income and depends on the ethnic group to which they belong.

This also applies to the chances of contracting an infection. Helicobacter pylori (the most common cause of gastritis and ulcers) affects groups with lower incomes more. Ethnic group also plays an important role: among African Americans and Latinos the infection is approximately twice as frequent as among non-Hispanic whites. And even within the three groups there is a gradient that flows in the opposite direction to the socioeconomic class, up to the creation of intra-family clusters. This is not, of course, a Stars and Stripes specificity. In South Korea, a study found that 22% of children were infected with H. pylori but with prevalence inversely proportional to socioeconomic conditions: 12% of children among the richest families, 25% in the middle class and 41% in the poorest groups.

Part of the explanation lies in the fact that the immune system needs an adequate general state of health to function optimally. Research has established that in the case of HIV infection, the immune system requires 20-30% more protein and energy (10% in asymptomatic patients). It is therefore not surprising that inadequate nutrition also plays an important role in immune dysfunction. Protein-energy insufficiency is estimated to be a major cause of immunodeficiency in developing countries.

Social pressures

It is not just the level of income that affects health status. Experiences of racial discrimination have been linked to low birth weight, high blood pressure and poor health. Making matters worse is the fact that whites often receive better care. According to the 2019 National healthcare quality and disparities report, in the USA, African Americans, Native Americans and Alaska Natives received worse care than whites for approximately 40% of the quality indices; Hispanics account for more than a third of the indices.

Similarly, gender-based discrimination has a negative impact on women’s health, with a 30% increase in levels of unhappiness, loneliness and depression. But they also have a detrimental influence on their self-perception, with a lower probability of feeling in excellent (or very good) health and a reduction in the number of Pap tests, mammograms and clinical breast exams.

There is also evidence that adolescents who identify as LGBT are more likely to exhibit depressive symptoms, suicidal ideation and self-harm. This phenomenon has been linked to the stress of having a stigmatized identity and experiences of social rejection.

The contribution of personal relationships

Even putting aside income, social conditions, ethnicity and gender, there may be factors that influence health status within individual categories. Social relationships, for example, can play an important role in managing the disease. According to the Swiss scholar Johannes Siegrist, the decision to use health services or not comes only after two further stages of the decision-making process. The first is individual and concerns the recognition of a symptom or health problem, but the second involves the circle of acquaintances. In this phase the individual seeks the advice of her partner, relatives, friends or other people she trusts.

At this juncture, social relationships play a significant role in how health disorders are recognized and interpreted. This hypothesis has been examined by several scientific studies. A meta-analysis found that the influence of social relationships on mortality risk is comparable to that of other known factors: overall the chances of survival increase by 50% in case of stronger social relationships. In detail, the ratios were equal to 1.9 for social integration, 1.5 for social networks, 1.4 for perceived social support and 1.2 for social support received.

Of course, having a strong support network also helps improve the outcomes of medical treatment. This is particularly true in chronic cases, where the presence of family caregivers can make a substantial difference.

Social epidemiology

Neglecting all these factors can be fatal to the effectiveness of public health programs and can lead to further imbalances in the population. In California, anti-smoking campaigns have led to a significant decline in smoking among citizens but not across all demographic groups: 19 percent of Native Americans, 23 percent of low-income African Americans, and 34 percent of non-smoking whites. have completed high school continues to smoke. In fact, the program has left the weakest groups behind, increasing the gap with those who live in the best conditions. A similar situation appears to have occurred with the lockdown measures introduced against Covid-19.

A study carried out in Italy by ASLTO3 and the University of Turin has highlighted that the socio-economic consequences of the restriction measures appear to affect the less advantaged social groups more frequently and more forcefully. In addition to the medium-long term effects on health (greater morbidity and mortality), they could cause short-term critical issues (particularly on mental health) and the use of adaptive and compensatory risk factors that are unhealthy for health, such as harmful lifestyles. . A time bomb that could drive an even greater divide between sections of the population in the future.

This is in addition to the fact that the direct effects of the pandemic were also different. According to Istat data, in March 2020, particularly in areas with a high prevalence of the epidemic, there were greater increases in mortality rates in the most disadvantaged population groups, which were already experiencing the highest levels of mortality even before the epidemic.

The concept of “syndemic”

Given the weight of pre-existing socioeconomic conditions, many observers – including The Lancet – suggest using the term “syndemic” rather than “pandemic”. The term was coined in the 1990s by the American anthropologist Merrill Singer to indicate the synergistic connection between health, environmental, social and economic problems and the presence of communicable and non-communicable diseases which creates serious repercussions on disadvantaged sections of the population. These situations should be addressed through what is called “social epidemiology”, an approach to health problems that incorporates the analysis of social experience and studies the mechanisms by which inequalities influence health.

As Singer states, such a strategy can be much more successful than simply controlling the epidemic disease or treating individual patients. In the words of The Lancet:

No matter how effective a treatment or protective a vaccine, the search for a purely biomedical solution to Covid-19 will fail. Unless governments devise policies and programs to reverse deep disparities, our societies will never be truly Covid-free.

From Aifa the first atlas on social differences and health

The Italian Medicines Agency presented the first “Atlas of social inequalities in the use of medicines for the treatment of the main chronic diseases” which investigates the correlations between access to medicines and the main socioeconomic factors in our country. According to the analysis, in the most disadvantaged areas of the nation, drug consumption is higher, probably due to a worse state of health. This, in turn, could be due to a greater spread of unhealthy lifestyles. “This is an evident phenomenon for almost all the conditions analysed,” explains the report, particularly for antihypertensive and lipid-lowering drugs and, in women, for antiosteoporotics.

The interpretation of the data relating to adherence and persistence is less clear. Although both parameters are higher in richer areas (with a decreasing north-south gradient), the profound differences between regional health systems could play a determining role. In fact, the levels of adherence and persistence remain the same even when the deprivation component is eliminated, suggesting that the differences actually derive from the presence of different regional healthcare systems.

In order to carry out a detailed analysis it would be necessary to be able to analyze samples deriving from the sum of individual cases in order to be able to correlate the individual events and have greater resolution power. This analysis, however, is based on results at population level and compares the Istat indicators relating to the different municipalities. In this way it is not possible to detect differences within a municipal population.