The “Demic” Team.

The year 2020 is going. Humanity lives the year of the comet and the plague. With a curious novelty. A very familiar word for all us, epidemic, is now ridiculed by its older relative. The powerful pandemic. They coexist with a third term associated with complex problems: syndemic. They would form part of the dangerous “Demic” Team. Epidemic, pandemic, and syndemic.

SARS CoV-2 and influenza virus. Photo on CDC

An epidemic equals a bad thing. It is an issue that affects many persons. The people or demos, that is, the set of individuals that make up a political unit. As a rule, epidemics are infectious: plague, tuberculosis, or Ebola.

There are also epidemics of hunger, obesity, unemployment, and stupidity. The Greek prefix pan means all or totality. It is the first half of pandemic voice. It is much more than the modest epi (it means on) defining epidemic.

An epidemic is local or regional. It does not matter if the region is extensive in several countries or states of a reasonable size. Famine in Africa or dengue in the Caribbean. A pandemic is broader: it affects most or all the world (like the 1918–1920 flu).

What is a syndemic?

It is a recent neologism, very young. It appeared in a book by Merrill Singer in 2009. Later, a significant article in the medical journal The Lancet in 2017 endorsed it. Syn and demic form the voice syndemic. Prefix syn is a component of synergy. It is a Greek word meaning cooperation or coordinated task.

We can define two or more causes whose effect is greater than the sum of the individual results. Demic is the borrowed core of the word epidemic common to epi-, pan-, and syndemic. Syndemic is the coincidence or sequence in time and place of two or more problems. They do not need to be infectious. Obesity, malnutrition, and associated health problems is an excellent pandemic example.

But this concept goes far beyond the coincidence of two or more comorbidities. Syphilis, HIV/AIDS infection, and intravenous drug addiction are syndemic. All with their complex social, psychological, legal, and health reality. Or tuberculosis and AIDS in Africa and Western prisons. The disease, my friend, is the precursor of poverty.

Is COVID-19 a syndemic?

Following Miller’s original syndemic concept, SARS-CoV-2 virus infection is a syndemic. Not as a ‘simple’ pandemic. The reason is clear. The most harmful pattern is a behavior not unrelated to several other problems. Some good examples are comorbidities, poverty, underdevelopment, personal and social vulnerability. As is usual, somebody disagrees with this opinion.

Coronaviruses behave with greater severity and mortality in Afro-American individuals in the USA. And much more than in white people. And in Latin Americans living there. There are thousands of elderly semi-convicted in rat traps (nursing homes). This occurs in many places on the planet.

It could be interesting to explain if two infectious diseases are syndemics. Flu and COVID-19. Each one with its accompanying circumstances. But, it is even more important to answer a question. Can we do anything to prevent the collision of these epidemiological asteroids?

It could be interesting to explain if two severe infectious diseases are syndemic. Seasonal flu and pandemic COVID-19, each with its accompanying circumstances, for example.

Every Fall Flu.

Flu is influenza and proceeds from Latin “influentia.” It means the influence of stars as a cause of some epidemics (XVI Century). The flu comes every year with the arrival of autumn. It lasts all winter. The Northern Hemisphere occurs between October and March. With a higher peak in January-February.

Seasonal flu. Photo on CDC

Most recent, deadly, and historic flu pandemics hardly respected seasonality. It seems that the current one for coronavirus walks in the same way. Each pandemic flu lasted what the flu virus “wanted.” The coronavirus will leave when it feels like it and will come back or not. Its cousins, the four respiratory coronaviruses, usually come back every fall.

Consider a non-pandemic seasonal level. The repetition of seasonal flu in our hemisphere justifies vaccines every year. Plus, the different flu viruses’ genetic capacity to change their antigenic structure.

Most recent, deadly, and historic flu pandemics hardly respected seasonality. It seems that the current one for coronavirus walks in the same way.

The vaccination campaigns start in October. The vaccine provokes an antibodies’ response of the persons vaccinated. The reaction can be optimal. It need be in coincidence with the flu’s most significant incidence (middle of winter).

A new seasonal epidemic cycle (autumn-winter 2020–2021) starts. Mass vaccinations also started. I beg whoever reads this article not to overlook the adjective “unpredictable.” The only thing predictable about flu is that it is unpredictable. It was some wise men’s idea. An idea from people recognizing they don’t know — as Plato said about Socrates (Plato’s Apology of Socrates).

The only thing predictable about flu is that it is unpredictable.

And the new coronavirus pandemic came.

The current 2020 year began with a significant problem. It is an incredible and devastating epidemiological co-factor. A catastrophe unknown before (the experts are waiting for a new pandemic flu). Since the beginning of the year, humanity suffers from a new respiratory virus. It is SARS CoV-2, different from flu viruses.

Now there is stiff competition between two pain multinationals. In this sense, it may be reasonable to ask what could happen if adding the viruses’ pathogenic effect. Even being respiratory, they also can damage other organs and systems. A significant part of the human body: heart, brain, kidneys, vascular system. And too social structures (health system, economy, collective morality).

This second assumption will sum more damage (they already do it). A fact that does not seem easy to avoid at once. The perfect storm. Not only for the possible victim (anyone) but also for the whole society. Let us say it without qualms: for the planet.

In that situation, society could be unable to withstand new healthcare stress. Health professionals’ morale is already below zero. Inept politicians and thousands of the last spring’s applauders deceived them. “What the happiest time!” could exclaim some optimist.

People were supporting health care workers in Spain (May 2020). Photo by AP Photos on Houston Chronicle.

In other words, one must consider the seasonal flu as a severe threat. In this biological war, victory or defeat will not depend only on science or politics. It is in the hands of each of us, citizens. The solution (prevention) is in the hands of civil society.

The solution (prevention) is in the hands of civil society.

Preventing, not regretting.

How can we avoid the added effect of flu and COVID-19? Or, at least, reduced? We do not have adequate and conclusive treatments. There are several drugs in research, but not yet available for the majority. Nor have effective vaccines, and well-tolerated (which will take longer). Be careful, guys, with the (possible) adverse effects! In science, as in research, haste is the wrong travel companion.

In science, as in research, haste is a wrong travel companion

It is necessary to put the focus on individuals’ behavior. But also on community efforts to facing the flu. There are solid arguments. Let us see. The flu situation in the southern hemisphere during the 2019 winter was excellent. There were 131,000 influenza cases in Australia. Now, 315; mortality did fall from 950 to less than 40, and none since June.

In New Zealand, the behavior has been similar or even better. From 57% of flu incidence in the previous season to 0.3% in the current one. And so, it seems that it has happened throughout the hemisphere below.

The reasons for this excellent news are the use of non-pharmaceutical interventions. Lower mobility of people by mass confinement, and the widespread use of masks too. Physical/social distance maintenance, frequent and adequate hand-washing. Of course, the general flu vaccination too.

The southern hemisphere model teaches us that we can combat the flu. It is about doing things right. We already know how to do it.

Effectiveness of Seasonal Flu Vaccines. Photo on CDC.

We need to get a suitable flu vaccine. And use the current even with a bad reputation because of its low effectiveness. It needs to improve. Must do a general flu vaccination in the current season.

Need to to do a general flu vaccination in the current season.

Note: The author declares any conflict of interest.




Medical Doctor (Infectious Diseases specialist/Professor of Medicine) and writer (narrative, theater).

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Agustín Muñoz-Sanz

Agustín Muñoz-Sanz

Medical Doctor (Infectious Diseases specialist/Professor of Medicine) and writer (narrative, theater).

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