Let’s Call COVID-19 A Syndemic - Honolulu Civil Beat

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About the Author

Seiji Yamada

Seiji Yamada is a family physician practicing and teaching in Hawaii.


Tonis Epel was from the island of Weno in Chuuk, one of the states in the Federated States of Micronesia. Mr. Epel was a schoolteacher, a board member of a community health center, a pastor and a community health worker.

Despite the fact that Mr. Epel had a number of health issues of his own, he worked assiduously to help others with their medical problems, serving as a go-between and interpreter for Chuukese in Honolulu who were navigating the American health care system.

Weno Island in Chuuk, the home island of Tonis Epel.

Tonis Epel was just the type of individual that the Hawaii Department of Health has been saying we need to lead and influence others in the midst of COVID-19 — a cultural broker who helped to mediate diverging points of view between patients and doctors, to track down patients at church or at their homes.

I first met Tonis in 2007, when he was on the board of the Kalihi-Palama Health Center and I began working there as the interim medical director. For the more than 18 years that I worked as a doctor at Oahu community health centers, I depended on people like Tonis every day. I still think about and miss the remarkable, dedicated community health workers I knew at Kokua Kalihi Valley (Melaia, Mili, Merina, Van, Tuphan and Manivanh) and at the Kalihi-Palama Health Center (Jina, Esther, Anita, Trinh, Van, Olivia, Cindy, Jane, Ming, Connie, Mildred, Christian, Teko, Mina and Millie).

Tonis Epel died of the coronavirus on July 7. He was one among many in the Micronesian community who have died. While non-Hawaiian Pacific Islanders are 4% of Hawaii’s population, by August they accounted for 30% of the cumulative cases of the coronavirus.

Mr. Epel’s funeral was attended by a broad section of the Chuukese community. It might have been an event where others were infected. If attendees were infected, they likely infected others in their households. Our Chuukese neighbors live as large, multi-generational families with little possibility of social distancing within households.

This crowding is largely a function of economic status. A February 2020 Department of Business, Economic Development and Tourism study comparing racial/ethnic groups in Hawaii found that the median family income of Micronesian families was one third that of the general population and only 7.9% of Micronesian families own their homes, as opposed to 58% for the total population.

Richard Horton, the editor-in-chief of the world’s most respected medical journal, The Lancet, last month provocatively titled his column “COVID-19 is not a pandemic.”

“We must confront the fact that we are taking a far too narrow approach to managing this outbreak of a new coronavirus,” he wrote, noting that the virus is interacting with an array of non-communicable diseases and “clustering within social groups according to patterns of inequality deeply embedded in our societies.”

Rather than a pandemic, he wrote, COVID-19 is a syndemic.

What is a syndemic? It is a set of linked health problems that interact synergistically and contribute to the excess burden of disease in a population. Merril Singer, the medical anthropologist who coined the term, notes that syndemics occur when health-related problems cluster.

Why is there so much obesity, diabetes and cardiovascular disease, as well as COVID-19, in the Micronesian community? Singer asks us to look at the pathways through which these diseases interact and urges us to examine how social inequality and injustice contribute to disease clustering.

These two graphs — which show the incidence of COVID-19 by race and the connection between race and income — illustrate the tie between poverty and COVID-19. Poverty is also tied to the co-morbidities (such as obesity, hypertension and cancer) that make COVID-19 more lethal. Per Capita Income by Race Group graph is from the Hawaii Department of Business, Economic Development and Tourism, March 2018.

Clearly, low purchasing power means poor quality food, which in turn means metabolic diseases which we know predispose to poor COVID-19 outcomes. Essential work that cannot be done on a laptop from home means that somebody brings the virus home. Crowded housing conditions mean that everybody at home gets the virus.

In conventional medical and public health discourse, we speak of how individuals have “risk factors.” Working at a fast food job is a “risk factor” for contracting the virus. Grandparents living with younger generations is a “risk factor” for the elderly to be exposed. We all know by now that age, obesity or diabetes are “risk factors” for a poor outcome of COVID-19 disease.

The risk factor model treats each individual as a discrete entity, a being unto itself. This individualistic view of conventional medicine and public health is in tune with the neoliberal organization of our society. As Margaret Thatcher famously said when she and Ronald Reagan were ushering in a neoliberal future, “There is no such thing as society.” That is to say, you’re on your own. If you can’t make it, you have nobody to blame but yourself.

Neoliberalism is the organizing principle of the modern world. I find it easiest to think of it as capitalism on steroids. Under neoliberal principles, profits are maximized by producing goods in countries where you can pay workers as little as you can get away with and the environmental regulations are lax (think of the soot-laden air of Chinese cities). You then burn more fossil fuel to ship the goods halfway around the world to big box stores.

Paid sick leave? If you don’t show up to work, of course you don’t get paid. I myself have seen a nursing home worker with respiratory symptoms (who was not Micronesian) refuse to get tested for COVID-19. He waved away my entreaties and fears that he might represent a public health disaster. He knew if he tested positive I would report it to the Department of Health, and he would be out of work for at least ten days. He couldn’t afford that.

The American health system is based on treating health care as a commodity. If you don’t have health insurance, you’re going to get a bill. Maybe you will go bankrupt. A large proportion of Micronesians in Hawaii are uninsured. They were covered by Med-QUEST at one time, but our state governors worked diligently to remove them from the rolls in 2015. Being uninsured is a powerful disincentive to seeking medical care.

COVID-19 need not have burned its way through the Micronesian community. Swift and thorough application of the principles of Public Health 101 — testing, contact tracing and quarantine/isolation  — could have prevented the worst of it. Yet, this was not done. Why?

Johan Galtung, the father of peace research, taught at the University of Hawaii from 1993 to 2000. In 1969, he coined the term “structural violence.” He defined violence as “the cause of the difference between the potential and the actual, between what could have been and what is.”

He continued, “If a person died from tuberculosis in the eighteenth century, it would be hard to conceive of this as violence … but if he dies from it today despite all the medical resources in the world, then violence is present.”

During the worst months of July and August, Micronesian individuals infected with the coronavirus often did not hear from the Department of Health for over a week. By then, everyone in the household was infected. Their doctors had a difficult time getting them into isolation or quarantine. When cases were found at the Legislature or Honolulu Hale, resources were surely mobilized more quickly. The difference between the potential and the actual has been stark.

In essence, the structural violence of disparities in infection and death from the coronavirus is a consequence of the neoliberal organization of our society. This social environment of neoliberalism determines the lived conditions of the marginalized (low wages, poor food quality, crowded housing or homelessness) that lead to the clustering of metabolic diseases and infectious diseases — in other words, to syndemics.

In contrast to conventional medicine, social medicine views social and economic conditions as key drivers of health or sickness. Using a social medicine lens to look at COVID-19, the diagnosis is of a syndemic. The prescribed treatment goes beyond simply addressing viral transmission to address social determinants of health.

The treatment is to advocate for a living wage and worker protections. It is to make possible local farming and access to nutritious food. It is to increase the proportion of affordable housing to luxury housing. For the sake of the survival of the human species, for the sake of planetary health, it is to stop emitting mass quantities of carbon.

In short, the treatment indicated by social medicine is overthrowing the neoliberal order. As Horton suggests, “Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food and environment.”

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The grotesque inequalities of our present world require fundamental changes. We must strive for a revolutionary reorganization of the bases of our economy and social relations. Human health and security, not profit, must become the drivers of human activity.

To begin, we need to agree that Micronesian Lives Matter. We cannot write off anybody. For a long time, I did not know that Tonis Epel was missing one of his lower legs. He had lost it to a diabetic infection and had had an amputation. Yet, with his prosthesis, he would diligently walk across King Street, from one building of the health center to another, to urge, wheedle or sometimes scold our patients to eat more healthily, exercise and control their diabetes.

We cannot lose our natural leaders like our community health workers. We must work to ensure that all have access to health care. The virus now burning through vulnerable populations affects all of us. We may not be equally as vulnerable, but we are all interconnected. We cannot defeat COVID-19 by focusing on the virus alone. To defeat the coronavirus, we must work toward a just and equitable society.

Postscript: The author obtained permission from Tonis Epel’s wife to mention his medical history.


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About the Author

Seiji Yamada

Seiji Yamada is a family physician practicing and teaching in Hawaii.


Latest Comments (0)

Thank you for writing this.

goodtrouble04 · 1 month ago

The government can barely do anything well; yet government-provided health care would be the anomaly? lolAlso, for those seemingly unfamiliar with Hawaii's health care system, Hawaii has a good health care system.  Just ask folks like federal or state/city employees who have quite the selection of excellent plans.Having health insurance is one thing.  Having good health care is entirely different.  You cannot expect good health care - or anything for that matter - while 'removing capitalism from the equation.'  

pueobeach · 1 month ago

Great article - the connection to capitalism is key to this syndemic!

GP_79 · 1 month ago

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