On Sunday 23^rd March 2020 Boris Johnson broadcast to the nation telling us to “stay at home” and isolate in an attempt to stem the spread of a virus named Covid 19 (Covid) which at the time we knew little other than since late in 2019 it had made its way round much of the world doing great damage in neighbouring countries such as Italy and France where the health care systems were barely able – and arguably on occasion unable – to provide health care.

Johnson’s announcement marked the beginning of what has come to be known as “the pandemic” which we will define as a “a widespread occurrence of an infectious disease over a whole country or the world at a particular time”. An epidemic in contrast is defined as “a widespread occurrence of an infectious disease in a community at a particular time:”. Thus the difference between them is one of scale or of spread. Covid was a pandemic as it affected the “whole country”, but had it affected only Glasgow it would have been an epidemic.  

It will however, be the thesis of this paper that what we have just experienced is better, and more accurately described as syndemic, which is defined by the Centers for Disease Control and Prevention (CDC) as “synergistically interacting epidemics,” meaning they are what happens when two epidemics—higher-than-normal levels of an illness in a community—occur at the same time.”

It is though important to note that  “a syndemic does not have to be limited to only diseases and medical conditions.” (https://www.health.com/Ocondition/infectious-diseases/coronavirus/what-is-a-syndemic) as the following example, unrelated to Covid, illustrates.

A pre-covid syndemic, according to public health experts in 2019 was described in the Lancet as “The Global Syndemic,” which researchers explained as three pandemics—obesity, undernutrition or malnutrition, and climate change—that affect people worldwide.”(https://www.health.com/condition/infectious-diseases/coronavirus/what-is-a-syndemic).

One thing to note here is that those most significantly affected by “The Global Syndemic” are those who are poorest or already most disadvantaged. For instance the evidence suggests that the poorer you are, the less healthy your diet is likely to be (eg more sugar, more fats, smoking, taking less exercise. One example is Glasgow, regularly at the top of deprivation league tables, which has “the lowest healthy life expectancy (HLE) in Scotland with men estimated to live for 54.6 years in good health and women for 57.6 years (2017-19).)

Climate change too affects the world in different ways, but typically the effects are greatest for poor countries. For instance it is possible that some island communities in the Pacific may be lost to rising sea levels.

The anguish of this is that, to quote the title of a book by Yanis Varoufakis “And the Weak Suffer What They Must”. As with obesity and nutrition the effects of climate change are not uniform but tend to affect the already deprived, and thus relatively less able to cope already, to a greater degree than those less disadvantaged. Perhaps were it  the other way round, climate change might be taken more seriously?

Deaths attributed to Covid in the UK amount to (at the time of writing – 16 July 2023) are 227,928 of 24,641,348 confirmed cases. Globally 6,950,642 died of 767,972,197 confirmed cases.

However an international comparison of Covid rates in different countries is made at best merely very difficult due to different policies on data collection, or even definitions of what constituted a Covid case. However there is good reason to expect death rates to be higher in less developed counties – being later in securing the vaccines, more difficulty in vaccinating the population due to a lack of infrastructure/ less well developed healthcare systems etc. However the map you will find here https://en.wikipedia.org/wiki/COVID-19_pandemic_death_rates_by_country shows, however counter intuitively that not only does this not appear to be the case but in fact that most of Africa had fewer deaths from Covid than elsewhere, including the industrialised world. For instance the only African countries with more than 1/3 of the rate of the United States and the UK were Tunisia and South Africa.

Was it that all of these countries did everything right while we got it all wrong? Or was the data collected there, whether due to the lack of capacity to do this (such that people died but never made it to the statistics) or that their government for their own political reasons did what they could to depress the figures. Or just didn’t/ could be bothered\ as they had other priorities? For instance in China where the pandemic begand, while it is known that their government took a robust approach to controlling outbreaks, their figures are remarkably similar to those in most of Africa. Likewise in India, despite the terrible reports of their healthcare system buckling under the strain to the point where families were being told to source their own oxygen as the Hospital had run out, their rate is the same apparent rate as Africa.

Therefore, noting the difficulty of an international comparison, we will instead focus on the UK as a case study of a syndemic.

Let’s start with social class. In 2020 Adam Tinson (https://www.health.org.uk/publications/long-reads/living-in-poverty-was-bad-for-your-health-long-before-COVID-19?gclid=CjwKCAiA9aKQBhBREiwAyGP5lRoWlMwy-b85v3Z9bHkO91dsV0xEnfT8xJ6pUajQ8djjO-Ms_Ks3QhoC36EQAvD_BwE) shows that in the 10 years before Covid, poverty trends were approximately flat (Poverty rates by household type, percentage of households below 60% of contemporary median income after housing costs: UK, 1994/95–2018/19) whether working age adults or pensioners though childhood poverty increased between 10/11 and 15/16.

These figures, though, look better because median incomes fell during this period as poverty increased among those least well paid while in-work and in rented accommodation. Similarly, he argues that it is the poorest who were most exposed to losing their jobs as a result of Covid. For instance it was their jobs that were most likely to disappear after the furlough scheme was brought to an end (though of course, ironically Brexit may have reduced these effects by creating a labour shortage).

Other signs of financial difficulties at this time are shown by

• a doubling in food parcels distributed by foodbanks and rising food insecurity
• sharp increases in non-payment of bills such as rent and mortgages
• 3 million applications for Universal Credit. (UKHLS data also shows that 3.6% of those in employment in January/February 2020 had attempted to or made a Universal Credit claim by April, rising to 7.3% for the bottom income quintile.)

Timson’s forecast, writing early in the early stages of Covid, was that there would be a negative effect on mental health and well-being, and he has been proved right.

A year later, writing in the Guardian, Owen Jones argued, “From the very start, the pandemic was always going to be shaped by the inequalities that define contemporary Britain. This is a virus that disproportionately inflicts the worst illness – and death – on those with underlying health conditions such as high blood pressure, diabetes and obesity, which disproportionately affect the poor. While middle-class professionals have the luxury of working in Covid-compliant homes, millions of working-class Britons cannot perform their tasks remotely. Many have no option but to cram into public transport en route to workplaces which often do not enforce safe social distancing to protect them. Recent statistics from the Office for National Statistics show that care-home workers and nurses are among those most likely to die from coronavirus, alongside machine operatives, home carers, chefs, restaurant managers, nurses and bus drivers.”

 (https://www.theguardian.com/commentisfree/2021/jan/26/combination-covid-class-devastating-britain-poorest)

In other words, the inequalities of Covid were not only structural but infrastructural, in that it was still possible to be a senior manager in a company while working from home, but not to work packing shelves  in your local supermarket is impossible. This is confirmed by the ONS observations quoted by Jones. Not all of the jobs might have been in the eye of the Covid storm (like care home workers and nurses, or home carers), but they can only be done if the employee is present (eg chef, restaurant manager or bus driver).

But what about other bases of inequality and not just income or class. What about race? In 2020 Caelainn Barr, Niko Kommenda, Niamh McIntyre and Antonio Voce pose the question why “Ethnic minorities [are] dying of Covid-19 at higher rate” (https://www.theguardian.com/world/2020/apr/22/racial-inequality-in-britain-found-a-risk-factor-for-covid-19) .

They found “that of 12,593 patients who died in hospital up to 19 April, 19% were Black, Asian and minority ethnic (BAME) even though these groups make up only 15% of the general population in England”. Therefore, either Covid was more likely to affect the BAME community (eg like Sickle Cell Anaemia) or they were being exposed to a higher level of risk.

Dr Zubaida Haque, who is deputy director of the Runnymede Trust, argued “There’s no question any more about whether BAME people are bearing the brunt of Covid-19; they clearly are.”

As we Thus, to understand Covid, we cannot treat it simply, only as a pandemic, which we defined above as ““a widespread occurrence of an infectious disease over a whole country or the world at a particular time”. This makes no mention of differential impact. A pandemic creates a risk that we face equally, but the above data shows the risk was not distributed equally. If you were poor, or part of the BAME community, your risk was greater.

A case study, albeit a historical one, will offer a practical illustration – the case of  Margaret Devlin, who was the youngest of three daughters born to William Devlin and Joan Devlin (nee Stewart). William, who was Irish and had been in the Irish Guards, and Joan, who was a book folder, married in 1888, aged 19 and 17 respectively. At this time the only thing worse than being Irish in Glasgow was to be an Irish Catholic, but William was an Irish Protestant. Given Joan’s family connections with the Orange Lodge it is very likely it was there that they met.

After their marriage William and Joan had three daughters – Mary (1890), Elizabeth (1892) and Margaret (1895). However, life was hard. William’s main skills, as a soldier were knowing how to fire a rifle and what to do with a bayonet, which have little demand outwith the army. During his marriage therefore, William was condemned to a series of poorly paid but physically demanding jobs, including railway porter, bricklayer’s labourer, and sheet metal worker’s labourer. I doubt if either bricklayers or sheet metal workers were well paid, which prompts the question how badly paid were their labourers?

In 1896, a few months after the birth of his third daughter Margaret, however, William Devlin died of, as the Death Certificate says “Chronic Bright’s Disease”, or, this  being protein in his urine, some form of kidney disease.

Three years later in 1899, Joan Devlin married again to Robert Russell, a Furnaceman, but in 1901, Joan developed  TB (Phithisus), succumbing to it after three years in 1904, leaving three daughters (aged 13,11 and 9) in the care of her elderly (64), widowed mother.  Particularly in these circumstances, family finances made it essential that the girls left school as soon as possible, aged 12. Indeed, by the time of her mother’s death, Mary already had, working as a “domestic servant”. However in 1907 aged 17, Mary died, like her mother of TB.

Elizabeth had also found work, eventually becoming a Psychiatric Nurse, working in the Royal Psychiatric Hospital in Glasgow as well as Dykebar in Paisley. The job was live-in and all found so accommodation etc was assured, though she was also paid a small allowance.

Mary, on leaving school the year after her older sister’s death, went to work in Belvedere Hospital, which was the Glasgow fever hospital, so in the event of an outbreak of such as Smallpox, Scarlet Fever, Phithisus (Typhoid to you and me), patients would be sent here.

Mary’s role was as a Ward Maid, and as such performed menial work, such as cleaning up sick, blood et. Nurse training had evolved by this time such as that this menial work was no longer done by them, but by such as ward maids etc, who would clearly be of lower status after Doctors and Nurses.

It is therefore perhaps unsurprising that in 1910, aged just 15, Margaret, according to her death certificate, died of an Enteric Fever Haemorrhage. Enteric Fever is now known as Typhoid, while the Haemorrhage is caused by Gastrointestinal (GI) bleeding  or intestinal perforation usually in the third of fourth weeks of illness.

Perhaps it’s important to be reminded that Margaret at the time of her death was only 15 years old?

So, how does this concern syndemics? Margaret is an individual example of syndemic, dying, like her mother and older sister, of a “poor folks’” disease (in their case TB). She was by the time of her death an orphan, under the guardianship of her aged grandmother, having left school as soon as possible as thus unable to secure any qualifications. She had nothing to offer but her labour, ending up as a dogsbody in a hospital where she was particularly likely to catch which epidemic of infectious disease was afflicting Glasgow. In short her social disadvantages put her in the cross hairs of infectious disease, just as Covid has exploited the most socially disadvantaged.

As Tinson notes,“Lower incomes are associated with worse health and this is particularly severe for people living in poverty. The longer someone lives without an adequate income, the worse the risk is to their health. This risk, in turn, can affect that person’s ability to find or sustain work, potentially resulting in a vicious circle of lower wellbeing, reduced productivity and a more limited ability to participate in society.”

As Owen Jones concludes “When we are finally through this nightmare, poverty will continue to rob the health and lives of working-class Britons. The class system is itself  and a public health crisis: the 20 most unequal countries are those with the worst health outcomes.”

Finally, a confession. Elizabeth Devlin – the middle of the three daughters – was my much loved Grandmother. Had she succumbed like her two sisters, I wouldn’t be here. That though is one of the vicissitudes of history, but it was not as though she remained untouched. Clearly, she lost her entire close family  – father, mother, older sister, younger sister – by the time she was 18. But the other aspect is that for 6 years, other than her grandmother, the only kin she had was an Uncle and cousin in Brechin, until she met and married my grandfather in 1916.

Margaret, had things been different would have been my mother’s Aunt Margaret, my Great Aunt Margaret.

Footnote: Alasdair has been extremely unwell recently, explaining his lack of posts recently. I feel sure all will want to share in my sincere expressions of concern and support for him.

Alasdair has agreed that I share some detail with you:

Hi John

Sorry to have been off the radar for so long, but since March/April I have been quite unwell. I don’t know if I told you about the cough I had had for some months, but in early April this was diagnosed as Interstitial Pulmonary Fibrosis, which means my lungs are losing whatever elasticity they once had. However, as I tend not to do things by halves, a week after I got this news, I suffered quite a severe heart attack that even though it happened in mid-April, and I was in hospital for a fortnight, I’m still in recovery. In the next few weeks, I expect to be back in again to “upgrade” the defibrillator that was fitted last time. It seems I need one to synchronise my heart as the left ventricle is a little tardy and is going to need something to bring it up to the speed of the rest. A trip to the bathroom is an adventure.

However, writing things like the attached are within my currently limited abilities.  You might remember I suggested this about two years ago – just a pity its taken something like this to get me to do it.

Best wishes

Alasdair