It is a syndemic not a pandemic – broader policies are needed

There was an article in The Lancet from its editor (September 26, 2020) – Offline: COVID-19 is not a pandemic – which questioned the “narrow approach” that governments were taking to the coronavirus pandemic based on the assumption that “the cause of this crisis … [is] … an infectious disease”. His argument is a whole of medical professionals have become prominent in daily press briefings and the like as they trot out the results of epidemic models and news agencies interview “infectious disease specialists” every other day. But the reality is that “(t)wo categories of disease are interacting within specific populations” – COVID-19 and “an array of non-communicable diseases” which are “clustering within social groups according to patterns of inequality deeply embedded in our societies”. He thus used the term ‘syndemic’ rather than pandemic to highlight the socio-economic distribution of the pandemic and focus attention on inequality and other forms of socio-economic disadvantage which interact with biological dimensions to determine health outcomes. He focuses on co-morbidities but I would focus on poor working conditions, poor housing, inadequate nutrition, the stress of poverty and poor urban planning that segments populations into leafy, low-density suburbs and suburban hell-holes where people are crammed in like whatever due to social inequalities and deficient government policy interventions.

Richard Horton writes that:

The most important consequence of seeing COVID-19 as a syndemic is to underline its social origins. The vulnerability of older citizens; Black, Asian, and minority ethnic communities; and key workers who are commonly poorly paid with fewer welfare protections points to a truth so far barely acknowledged-namely, that no matter how effective a treatment or protective a vaccine, the pursuit of a purely biomedical solution to COVID-19 will fail.

He wants governments to “reverse profound disparities” and unless they do, the sort of risks that COVID-19 has exposed all of to will persist.

He wants a “national revival”, which is an important and necessary condition to dealing with the issues he raises.

But a necessary condition is not a sufficient condition.

Much of what he is talking about has been created or exacerbated by neoliberal ideology and the type of policies that my own profession has claimed would successfully lead to convergence and prosperity, when they knew all along, they were serving the interests of rising inequality and divergence.

As Richard Horton concludes:

The economic crisis that is advancing towards us will not be solved by a drug or a vaccine. Nothing less than national revival is needed. Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment. Viewing COVID-19 only as a pandemic excludes such a broader but necessary prospectus.

The problem is that the economic crisis is not ahead of us as he suggests (“advancing towards us”) but has been building for decades.

Even before the pandemic, the signs of crisis were there for all to see.

Indeed, the conditions for the ‘syndemic’ were not produced overnight.

It took some decades of relentless retrenchment of welfare support, privatisation, outsourcing, elevated levels of unemployment, the rise of underemployment, the suppression of wages growth, the cuts to essential services, user pays, and all the rest of the agenda to create societies that not only distribute national income disproportionately to the top-end-of-town, but have become increasingly fragile to economic disasters.

Just today the ILO issued a report (which I haven’t yet read fully) that showed that the pandemic has created jobs losses “four times worse than those of the global financial crisi in 2009, worse even that the Great Depression. But the ultrawealthy have seen their wealth soar” (Source).

How is it possible to accept economic structures that create so much harm and suffering for the majority yet allow the ultrawealthy to gain more wealth – and power?

While regular readers know I do not support the faux-progressive call to “tax the rich to pay for essential services” narrative, I do support taxing the rich to stop this obscene skewing of power.

There is a 30-year old study – Global Burden of Disease Study (GBD) – that is conducted by The Lancet in collaboration with the – Institute for Health Metrics and Evaluation (IHME) (a health research centre at the University of Washington).

This study provides valuable data through the – Global Health Data Exchange (GBDx)

You can also read about it – HERE.

This paper – Five insights from the Global Burden of Disease Study 2019 (published October 17, 2020) – provides a valuable summary of the 2019 study.

They found that the pace of improvement in their Socio-demographic Index (SDI) which attempts to measure socio-economic well-being “accelerated from 1950 to 1980” but has stalled since then.

The neoliberal era has not been kind to broader well-being.

An overwhelming result is that:

Social and economic development, measured with SDI, is highly correlated with health outcomes … Given the overwhelming impact of SDI on health progress, doubling down on policies and strategies that stimulate economic growth, expand access to primary and secondary schooling, and improve the status of women should be our collective priority …

Governments should invest more funding in research and action to tackle these stagnating or worsening risk exposures. A core obstacle to accelerating progress on behavioural risks is the notion of individual agency and the need for governments to let individuals make their own choices. This concept is naive, given that individual choices are influenced by context, education, and availability of alternatives. Governments can and should take action to facilitate healthier choices by rich and poor individuals alike.

A related report from Victoria University in Melbourne sponsored by the US Chamber of Commerce (published September 2020) – Increasing Social and Economic Benefits Globally – shows that for the 27 countries studied:

… ill-health has a severe impact on economic growth for all countries included in the study, ranging from 5.3% (Mexico) to 8.2% (United States) in 2015 and rising to be between 5.7% (Singapore) and 8.4% (Poland) by 2030 …

… there is a powerful economic argument for investing more in NCD prevention and treatment so that people can work more productively, thereby reducing social and economic exclusion, and improving the health resilience of the populations …

Fiscal austerity of the type advocated by the likes of the IMF and many mainstream economists often targets the health sector for cuts.

The cuts have no basis in science or knowledge.

The opposite is true.

Strong investment in public health and keeping private rent-seeking medical firms out of the public funding picture deliver massive returns in the form of productivity growth, lower health care costs overall and longer lives for workers, particularly lower-income workers.

In the last week, the British Office of National Statistics (ONS) published their latest – Economic well-being estimates from the Survey of Living Conditions, Great Britain (January 21, 2021) – which bears on this discussion.

The main points of the data release are discussed in this press release (January 21, 2021) – Personal and economic well-being in Great Britain: January 2021.

The UK is being devastated by the COVID-19 spread and it has exposed the vulnerabilities left by years of abuse of one of the most valuable things Britain has – its National Health Service – at the hands of myopic and misguided governments.

Clearly, private medical providers have done well out of the ‘privatisation by stealth’ strategy that successive British governments have pursued as they fell prey to stupid claims by economists that they needed to cut deficits.

We already know that low-paid workers are disproportionately impacted by the job losses associated with the pandemic (syndemic).

The ONS data shows that:

The labour market shocks associated with the coronavirus (COVID-19) pandemic have been felt more by young people and the lowest paid; people aged under 30 years and those with household incomes under £10,000 were around 35% and 60%, respectively, more likely to be furloughed than the general population.

And these workers are more exposed to the virus because of the nature of their workplaces and their lack of discretion in determining work location.

Higher paid workers have been able to shelter at home offices while the virus rages outside. They can afford home deliveries of all types. They can effectively insulate themselves from the health harm.

But lower paid workers are unable to protect themselves in that way and many are on the front-line protecting the rest of us – cleaners, nurses, rubbish collection personnel, etc

But that higher risk exposure is multiplied because it is also clear, from years of research, that socio-economic status and health are closely related.

The better off a person is the better health circumstances, on average, they enjoy.

This report from the Australian Institute of Health and Welfare – Australia’s health 2016 – provides strong evidence to support that proposition, evidence that is replicated in multitudes of studies across the world.

The “the lowest socioeconomic group was 29% higher than in the highest socioeconomic group” to exhibit the standard ’causes of death’ and:

Rates of potentially avoidable deaths-premature deaths that could have been avoided in the presence of timely and effective health care-were 1.8 times as high in the lowest socioeconomic group, compared with the highest

So not only do the lower-paid workers and their families face higher exposure to the virus, but they go into the situation with much higher health risk factors from underlying conditions.


The agenda outlined in our book – Reclaiming the State: A Progressive Vision of Sovereignty for a Post-Neoliberal World (Pluto Books, September 2017) – aims to address these systemic vulnerabilities.

It isn’t enough to vote and elect Labour governments (or whatever they are called wherever) who advocate austerity-lite policies and just play the neoliberal game, perhaps in a more civilised or less crude manner.

We have to create political movements that prioritise dealing with the structural creation of poverty and disadvantage.

That means a headlong charge into the power elites. They have to be disenfranchised.

Otherwise, no significant progress will be made.

If we didn’t already know that then surely the syndemic has brought it home in spades.

Public Lecture – Tuesday, January 26, 2020

I will be giving my annual public lecture for the Helsinki Centre for Global Political Economy (as part of my professorial role at the University of Helsinki) on Tuesday, January 26, 2021.

The topic will be “Political Economy Thought and Praxis Post Pandemic” and I will explore familiar themes.

All are welcome.

It will be a live stream on YouTube –

The Stream will begin at

18:15 Melbourne time (Australia)
9:15 Finnish time (GMT+2)
7:15 London

and whatever for Japan, US etc.

I will speak for around 40 minutes and then take questions and discussion.

That is enough for today!

(c) Copyright 2021 William Mitchell. All Rights Reserved.

This Post Has 8 Comments

  1. Bill, I think you intended to write, ‘a whole (lot) of medical professionals. Absolutely right and necessary article. The powers that be have done a great job of keeping the focus narrow. During the 1st UK lockdown, we did hear the odd word of how we couldn’t go back to business as usual, but that sound has been pretty much channelled out as the government puts all effort into exactly getting us back to business as usual, unfortunately without even paying the virus due respect not to interrupt the plan.

  2. One of Bill’s best posts when it comes to timely and urgent importance. Truly magnificent IMHO. I take slight issue with only one sentence: “That means a headlong charge into the power elites. They have to be disenfranchised.” Not feasible for us any longer, I’m afraid; the time for such a headlong charge, even had we managed to amass sufficient “soldiers,” has passed. But there is time for something else, for changing the minds and hearts of the power elites, and, being human, at least a significant portion of them presumably have the latter as well as the former. The most recent Davos rhetoric gives some reason to so believe. Yesterday, I stumbled upon an advertising group (of all things) from the UK called “The Great Reset” and have never felt more hopeful since neoliberalism began to tighten its vise-grip back in the 1970s and 80s. Some MMT folks–I would hope, Bill himself–should make it a priority to get in touch with this group (search for “the great reset advertising”) and help them to see and analyze more clearly through the MMT lens, explaining, for example, why a JG would be so much more effective in reaching their goals than a GAI.

  3. @Newton Finn. I guess we should also feel slight optimism when the UK Guardian has an editorial directly referencing Bill Mitchell even if the link under Bill Mitchell is to a previous Guardian article and the employment buffer stock link seems to be to a report by L. Skidelelsy commissioned by J McDonnell about shorter working hours. I guess we’ll know whether this is a real lesson learned when they stop quoting every utterance of the IMF as if it was gospel.

  4. Many groups at our university has formed a union and are fighting for basic article 23 human rights to dignified employment. People are fighting and learning in the process. There must be a labor movement. People are explicitly educating others that we must band together and perform concerted action to force change outside of electoral system or parallel to it. That is the way.

    Obviously disagree with Newton on changing minds. I have never seen an example where debate/argument by itself won the working people anything. Nobody would NEVER utilize “changing minds” on even our university board of directors as central strategy, let alone the nation! Trying to convince these people is cul-de-sac. We do that as PR mainly and to embarrass them (which works too). We force them to give in by going on strikes, which is the most powerful tool we have.

    I can tell you that the COVID stress has made me much less productive at work, at least by a third. It takes so long for us to order anything because items are running out. Two of my students are not getting valuable lab experience because of COVID. Its just a mess.

    The dichotomy that we have to choose health vs economy is false. Clearly, when people are healthy mentally and physically, the economy is better and more productive.

    As for inequality of health outcomes, our professors are staying home since mid-2020 while our primarily women of color laboratory helpers must rely on public transportation to get to work everyday (yes, even when there is a stay-at-home order). A lot of them got COVID19 as well, but thankfully none have suffered loss of life from the virus.

    Inequality and destitution is closer than what some people may like to think.

    The pandemic hopefully will be over in 1 or 2 years but the syndemic will not be over for sure.

  5. What we like to think of as representative governance is representative of one form or other of entrenched, systemic privilege. Money and economic power come from privilege and are converted into political power. How might this system of privilege be dismantled? Let us consider doing away with the election of legislators, replaced by a lottery. Any adult willing to serve on a legislative body would be required to take and pass what amounts to a civics examination to demonstrate competency. When a vacancy in the legislative body becomes available, someone is then chosen to fill the vacancy for one term, after which he or she returns to private life. The result: participatory democracy unburdened by corporate and other vested interests.

  6. Great article for reference It always make sense when problems/ events are approached in an economic context!

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