Covid’s Co-pathogenesis, by Matt Sparke and Lucia Vitale

By paying close attention to all the social pathologies and inequalities that have coincided and interacted with Covid-19 to make it so harmful, we offer here a syndemic account of the pandemic’s co-pathogenesis that acknowledges both the situated nature of disease vulnerability and the capitalist connections between outbreak hotspots and unequal outcomes. These connections are consequential, but the contexts of co-pathogenesis matter too. From the environmental upheavals and the viral breeding grounds of food chains supplying Chinese mega-cities (and thus global supply chains), to the suffering experienced in the death pits of the corporate ‘care-home’ industry across the western world, to the vaccine apartheid and new viral variants made possible by the successful market failure of patent rights on vaccines, Covid has exploited and exposed vulnerabilities created by capitalism. But it has done so in ways that are also co-determined by many other social determinants of disease, including racism, xenophobia, and patriarchy, as well as other diseases such as HIV-AIDS, tuberculosis (TB) and diabetes that have themselves been deeply shaped by capitalist inequalities and the historical legacies of empire. 

Co-pathogenesis is such a useful term precisely because it helps us describe these connected-but-clustered ill-effects as Covid has moved through the global body politic. This movement can in turn be reviewed across two types of syndemic scene: the first represented by disease emergence and evolution; and the second by disease spread and suffering. Unfortunately, the curtain has not come down on either of these ‘scenes.’ And we are now entering a third extended scene in which ‘long Covid’ looks set to become a name for a global and social condition of co-pathogenic affliction as well as a description of enduring pathology in the bodies of individuals.

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Covid-19’s viral origins lie in capitalist upheaval. As Robert Wallace and his historical-materialist microbiologist colleagues have shown, the emergence of the pandemic can be traced to the market frontiers of the food chains supplying urbanizing China.^[4] Instead of pointing an orientalizing finger at the ‘China Flu’, they map the breeding grounds of the virus at the intersection of globally financed investments in the corporatization, consolidation and monopolization of agriculture on the market frontiers of fast-growing cities.

“Market frontiers” means two things in this context. It means, first, that these are sites of rapidly advancing, resource-commodifying capitalism, churning through and transforming rural habitats. But, second, it also means zones where neoliberal and non-neoliberal norms of governance mix. In China, much of this crash program of industrialization took place under the guidance of a state that has its own pro-market agenda – one that pushes more and more people into capitalist ways of life with scant regard for the health consequences.

Mapping all the circuits of capital coming into and out of these viral breeding grounds, Wallace and colleagues proceed to identify the following seven factors underlying the zoonotic emergence SARS-COV-2:

1. global circuits of capital, including the corporatization of agriculture;
2. capitalist destruction of ecologies that once kept pathogens in control;
3. increases in the rates and taxonomic breadth of zoonotic spillover events;
4. commodity chains moving sick livestock and labour from hinterlands to cities;
5. global travel and trade networks that move pathogens from cities to the world;
6. network-enabled evolution of greater pathogen transmissibility and deadliness; and
7. replacement of natural selection as an ecosystems-based form of disease protection.^[5]

Covid’s market frontier breeding grounds lie at the intersection of these seven factors.

Even aspects of the story seemingly out-of-keeping with the ‘market frontier’ hypothesis are not in fact so discordant. Take the ‘wild foods’ (pangolin, snakes, bats) associated with the Wuhan wet market that, for now, still features in most accounts as the pandemic’s birthplace. Wallace and colleagues argue that the commodification of ‘wild foods’ is itself increasingly part of a global neoliberal order – offering producers squeezed by the monetization of the countryside a chance at economic survival. In their words:

Studying Covid-19’s emergence in terms of co-pathogenesis therefore means grasping the extent to which neoliberal capitalism was an enabler in its viral leap between animal and human populations.

In summary, crisis-inducing capitalist processes of financialized agricultural intensification, deforestation, and trade liberalization came together with rapid urbanization and food market consolidation. Such developments worked together ‘syndemically’ to connect Chinese food supply chains with their global commodity counterparts. Covid-19 is not just a natural disaster, therefore. It is, in large measure, a neoliberal disease.

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If the origins of Covid-19 can be located in neoliberal capitalism, its consequences have been no less shaped by it. The way in which Covid has subsequently been treated as an opportunity for profit and market capture by pharmaceutical firms has led to yet more disaster. The emergence of the Omicron ‘Variant of Concern,’ or VOC, late in 2021 should also be looked at this way in terms of co-pathogenesis. The associated shifts in viral code have only occurred because of an abundant supply of unvaccinated susceptible bodies in which the virus could evolve. Such unprotected bodies are numerous indeed in the Global South. Vaccine profiteering – and closely associated tactics of vaccine hoarding by rich countries – have meant much of the world’s population is still at risk.

As wealthy countries move on to third and fourth doses of vaccines with high efficacy, low- and middle-income countries are stuck with less efficacious vaccines – or simply no vaccines. Many have hardly any means at all of protecting their populations against Covid. Compounded syndemically by racist double standards that look a lot like those made infamous by imperialism and South African racism, this vaccine apartheid also clearly has capitalist origins in the neoliberal trade rules that have prevented the speedy roll-out of universal vaccination worldwide. As the scientific editors of the International Journal of Infectious Diseases have put it: “Less than a fifth of people in Africa have been fully immunized against Covid-19, including millions of health workers and vulnerable populations. There remain many unvaccinated vulnerable populations around the world, and every month thousands of people are still dying of Covid-19. The more SARS-COV-2 circulates and transmits, the more VOCs evolve.” Moreover, the authors note,  “the further evolution of variants may eventually lead to variants resistant to vaccines. One of the contributing factors to emergence of VOCs is the low vaccination rates in parts of the developing world, particularly Africa.”^[7]

Many have protested against this pattern.  Health justice advocacy groups such as Free the Vaccine, Right to Health Action, Médecins Sans Frontières (MSF), and Public Citizen, as well as numerous officials and public intellectuals in poor countries, have raised their voices against it. Among the latter, activists from the Free the Vaccine movement wittily put their critique in the form of an updated version of The Twelve Days of Christmas:

There are many co-pathogenic consequences of a vaccine that is still not free for most of the world. They now include the variants boomeranging back to rich countries. The result is increased danger from variants for everybody and more proof, if any were still needed, of the wisdom of the WHO warning that “None of us are safe until all of us are safe.”[9]

All of the critiques and warnings have nevertheless been drowned out by more influential advocates of intellectual property rights and business-knows-best solutions. According to UK Prime Minister Boris Johnson, the capitalist fix for Covid was simple. “The reason we have the vaccine success is because of capitalism,” Johnson bragged in March 2021, “because of greed my friends.”^[10] The emergence of the Omicron variant has since undermined this rosy-tinted view. Now even Johnson’s appreciative audiences have had to grasp what his capitalist fable ignored: viruses evolve. If capitalist conceptions of intellectual property leave millions of people around the world cut off from vaccines, the virus evolves accordingly. Meanwhile, if capitalist condemnation of public health protections leads – as it has done in the UK and US – to the repeated repudiation of masking and vaccination in the name of market freedom, it generates, in rich countries too, more infection, hospitalizations and opportunities for mutation. The result is much more suffering and death, and along with it a kind of collateral co-pathogenic conversion of the traditional Hippocratic Oath – ‘First, Do No Harm’ – into its uncaring Covid-era update – ‘First, Do No Harm to Capitalism.’ 

Some critics point out that much more than capitalist intellectual-property regimes stand in the way of the roll-out of mass vaccinations in poor countries. They highlight limited manufacturing capacity that curtails tech transfer, inadequate vaccine delivery systems, lack of professional expertise, and vaccine hesitancy in poor communities. As mRNA vaccines received emergency authorization from governments around the world, Bill Gates gave an interview contending in this way about other obstacles being much more relevant than the need for IP sharing. He told Britain’s Sky News in April of 2021,

Well, there’s only so many vaccine factories in the world, and people are very serious about the safety of vaccines…The thing that’s holding things back in this case is not intellectual property. There’s not like some idle vaccine factory, with regulatory approval, that makes magically safe vaccines. You know, you’ve got to do the trials on these things, and every manufacturing process has to be looked at in a very careful way.^[11]

On-the-ground investigations have contested such claims.^[12] The Global South in fact does have the manufacturing and logistics capacity to turn out and deliver vaccines. Denials from wealthy countries tend thus to look more like delaying tactics in the service of the “greed” glorified by Johnston. Alongside these capitalist complicities, though, we also see the co-pathogenic effects of racist ‘blame the victim’ narratives too. The people of the Global South, in these narratives, are the authors of their own misfortunes, not least of all because of their backward distrust of western medicines and vaccines. Vaccine hesitancy can thereby be elevated as an excuse in place of concerns about vaccine access, all the while ignoring how drug trial mistreatment, data extractivism, and the geopolitics of vaccine diplomacy have bred mistrust of western vaccines. As a recent ‘Call to Action’ by African health leaders in the Lancet has put it: “A history of colonial medical and vaccine research abuse in Africa diminishes trust in current vaccines. … Vaccine hesitancy in Africa is also linked to the duplicity of the global community…, compounded by vaccine diplomacy and donor dependency.”^[13]

In other words, to the extent that African vaccine hesitancy exists, it too is another boomerang effect of elevating core capitalist concerns of the rich world over the health of the global south, and indeed, of ordinary people everywhere. When it is used as an excuse for uncaring complacency about poor people going without vaccines, we see how capitalist and colonialist power relations spiral forward together in evolving forms of co-pathogenesis.

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The spread of Covid also reveals how co-pathogenesis continues to spiral through multiple interacting social vectors. An inventory of the neoliberal contributors to this co-pathogenesis helps underline how wide-ranging it is, spreading from neoliberal social norms and divisions of labour, through diverse hotspots of heightened risk, into the neoliberalized healthcare sector itself.

Huge inequalities in both wealth and income between elites and everybody else have shattered older forms of social solidarity, undermining social capital, and leading more neoliberal societies to lack both the institutions and the will to address health inequalities in the crisis. 

Beyond the workplace, many others in neoliberal societies have been made vulnerable because of the effects of supposedly pro-market policies that have undermined healthcare, welfare and social safety nets. Some went into the pandemic suffering from pre-existing medical conditions such as diabetes, obesity, hypertension, TB and HIV that themselves widely map on to poverty and deprivation. Some were treated to lectures about social distancing and sheltering-in-place, all the while being trapped in cramped multi-generational households or on the streets with no home in which to shelter. And yet others have seen the food, water, social and medical services on which they depend overwhelmed, displaced or turned deadly by the crises Covid-19 has caused. While care homes in rich countries have been turned into death traps, inhabitants of informal settlements in the global south have seen their already precarious food and water supply systems completely disrupted. 

Meanwhile, across the world in rich and poor countries alike, for-profit healthcare providers and insurers have been shutting down and withdrawing services. Their revenues from elective procedures have been dropping, the burden of Covid patient care increasing, and so their bottom lines have had to adjust. Those that have managed to stay open are in turn being stressed by the huge waves of withdrawal and resignation by health care workers who, thanks to neoliberal principles of cost containment, find themselves under-supported and over-worked to the point of collapse.

Across all these sites of neoliberal co-pathogenesis, the ‘First Do No Harm to Capitalism’ principle of prioritising profits and market freedom over public health has further compounded problems of poor service and confusing communications about the risks posed by the pandemic.  It has even led in some places to the complete corruption of respected epidemiological ideas about creating ‘herd immunity’ through mass vaccination. Instead, we have seen advocates of laissez-faire market freedoms justify a ‘let it rip’ approach to the pandemic. They revisited the time-honoured concept of herd immunity and reformulated it in a Social Darwinistic way, with policy prescriptions that, at bottom, meant sacrificing those deemed weak and thus non-herd. Frequently the resulting abandonment of all those sacrificed in the name of free market fundamentalism has implicitly been justified with diverse kinds of nationally and racially-marked ways of being fundamentally uncaring about others.^[14]

Systemic racism, although not neoliberalism’s invention, has powerfully intersected with many other patterns of vulnerability and suffering in the pandemic. The racially unequal outcomes of Covid-19 have been especially obvious in the US. As in previous pandemics, American communities of colour have suffered more cases and more deaths per capita.^[15] Vast disparities in Black and white health result from long-standing legacies of enslavement, legal segregation, white terrorism (as in the lynchings of the Jim Crow age), massive imprisonment, and police terror, along with ongoing discrimination in housing, employment, and elsewhere.^[16]

In a pandemic, though, all of these longstanding patterns take on a new visibility and life-or-death implications. Crowded into projects and prisons, and often concentrated in dangerous front-line work, Black populations across the United States have been sacrificed for the health of a neoliberal order.

Latin America, with its distinctive politics of race, offers us more but distinct examples of this pattern. Here Mestizaje – or the post-racial concept that Latin American blood is a harmonious mix of African, European and Indigenous ancestry – remains a dominant frame for explaining racial identity. Leaders in the aftermath of independence movements across Latin America capitalized on this unifying idea in order to build nationalist sentiment throughout the region, a political project whose enduring legacies “in effect suppressed the visibility and recognition of Indigenous and Black people in the region.”^[17] For example, census data collection by race in most Latin American countries has been inconsistent and uncommon, with only a handful of countries collecting data by Indigenous status, and just two (Brazil and Cuba) consistently collecting census data by Afro-descendance.^[18]

But Mestizaje only goes so far, as the pandemic has cruelly revealed. Patricia Pinho argues that in Bolsonaro’s Brazil neoliberal discourses on meritocracy – if you are rich, you deserve to be – work to make inequality seem entirely natural and unavoidable.^[19] Racialized minorities are caught in a situation in which white people are regularly considered meritorious. People come to identify their own failures and successes in terms of their own personal merit, a dynamic which occludes how individuals belonging to different racial groups experience distinct levels of privilege. And in a time of pandemic, crucially, their individual health and well-being is also seen to be a reflection of their good characters. State policies, such as the undoing of affirmative action programs, reflect this outlook. In this local, contemporary context we see both how Covid-19 reveals how racism and capitalism have combined pathogenically in a series of “syndemics” over time and how directly this co-pathogenesis affects the lives of everyday people.

In Mexico, Abril Saldaña-Tejeda has documented how the pathologies of class and race have interacted on the pandemic’s front lines. “Covid-19 doesn’t exist in isolation and requires that we consider social and structural conditions as pre-existing and problematic,” she argues. “Some of these conditions are embodied by individuals (i.e., age or co-morbidities), but others are found in institutional practices and policy approaches to address Covid-19.” In the context of a public emergency, pre-existing conditions create what she calls a bioethics of “extreme triage.” Hospital staff make speedy decisions about how to allocate medical resources, at a time when their resources are close to overwhelmed with Covid patients. Many such life-and-death decisions hinge on evaluations of a patient’s future high-quality “life years.” Vulnerable populations – poor, racialized, older, often suffering from a large number of other ailments – often do not make the cut.^[20] Economic inequality therefore combines with racialized inequality, creating an array of intersectional pathways down which disease and suffering spread.

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​​The pandemic’s crises and consequences have exploited, exposed, and exacerbated health fragilities in unique and localized but also connected ways, necessitating a syndemic analysis which accounts for local clustering, global connections, and their resulting forms of co-pathogenesis on the ground. Our argument is that to gain a holistic picture of these situated, yet connected Covid syndemics around the world, we must consider social vectors of disease and how they interact with capitalism in various forms of connected but context-shaped co-pathogenesis. The resulting forms of co-pathogenic affliction now look set to be long-lasting. And just as responses must be holistic in grasping the intersectional imperatives involved in the co-pathogenesis of long Covid in individuals, they also need to be just as holistic in adjusting to living with Covid as a global phenomenon over the long term.

It has become a commonplace of the pandemic to claim that it has exposed social vulnerabilities. It is also clear that the various forms of co-pathogenesis discussed here illustrate how the virus has exploited these vulnerabilities to evolve, spread and overwhelm many of our best protective efforts. In doing so, it has also immeasurably exacerbated our vulnerabilities too.

Co-pathogenesis helps us name and understand this pattern. The unfettered pursuit of profits under global neoliberalism lies at its origins. The same paradigm’s weakening of public institutions, especially those devoted to public health, explains much of Covid-19’s subsequent career. And neoliberal precepts combine with the effects of the virus to undermine public health and enable disaster capitalism to spread like a virus itself.

As a representative of the Dominican Republic’s Ministry of Health (‘Consuelo’) has remarked,

The commercial war of vaccines has negatively affected vaccine coverage. If we hadn’t had this interference, if we had had a response that was more collective, we could have reached a percentage of vaccine coverage much higher than what we have so far. But since in a commercial war economic interests rule, this collective response was not possible. Capital is betting on the failure of our public healthcare system.^[21]

Consuelo’s comments suggest just how interconnected the crises aggravated by Covid are. His argument reveals both the near impossibility of a collective, public response to the pandemic under neoliberal capitalism, and the related weakened public health systems which are not just a result of neoliberal capitalism, but also rely on its continuation to survive.

Neoliberal forms of organizing society have taken over social solidarity models in many places around the world, resulting in weakened national abilities to organize a collective Covid response. As elites have profited from the crisis, hiding away in cosy private enclaves safe from infection (knowing, of course, that concierge medicine is always within financial reach), disenfranchised communities have seen disproportionately high rates of Covid-19 death and suffered intense economic reverberations. The rich have gotten richer while maintaining freedoms against restrictions on their movement or the hoarding of resources. The poor have gotten poorer, their movements constrained, and their political and economic futures sacrificed.

In all these ways, the pandemic has revealed how social pathologies cluster co-pathogenetically with disaster capitalism to produce interconnected, yet situated syndemics around the world. As a result, vulnerable societies, just like vulnerable individuals, are being set-up for forms of long Covid that lock disaster into our future. We desperately need to find portals out of the pandemic that point in less disastrous directions. But finding them demands that we first come to terms with all the different social pathologies coinciding in Covid-19’s co-pathogenesis.

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Citations

[1] For a comprehensive analysis of Covid’s neoliberal codetermination, see Matthew Sparke and Owain David Williams, “Neoliberal disease: Covid-19, co-pathogenesis and global health insecurities,” Environment and Planning A: Economy and Space (19 October 2021). DOI. On its intersection with and intensification of other inequalities see Oxfam, Inequality Kills: The unpalleled action needed to unprecedented inequality in the wake of COVID-19, Jan 17, 2022, Link to article.

[2] Richard Horton, “Offline: Covid-19 is not a pandemic,” The Lancet 396, no. 10255 (26 September 2020). DOI.

[3] Emily Mendenhall,  “The Covid-19 Syndemic Is Not Global: Context Matters,” The Lancet 396, 10264 (2020): 1731.  DOI. Emphasis added.

[4] Robert Wallace et al., “Covid-19 and Circuits of Capital,” Monthly Review, 72,1 (2020) Link to article.

[5] Wallace et al., “Covid-19.”

[6] Wallace et al., “Covid-19.”

[7] Eskild Petersen, Francine Ntoumi, Davis S. Hui, Richard Kock, Giuseppe Ippolito, and Alimuddin Zumla, “Emergence of new SARS-CoV-2 Variant of Concern Omicron (B.1.1.529)—highlights Africa’s research capabilities, but exposes major knowledge gaps, inequities of vaccine distribution inadequacies in global Covid-19 response and control efforts,” International Journal of Infectious Diseases 114 (1 January 2022), 268-272. Link to article.

[8] Merith Basey et al., “The 12 waves of Covid,” Free the Vaccine for Covid-19 blog, 23 December 2021; Link to website.

[9] https://www.who.int/news-room/commentaries/detail/a-global-pandemic-requires-a-world-effort-to-end-it-none-of-us-will-be-safe-until-everyone-is-safe

[10] Pippa Catterall, “‘Greed, my friends’: has Boris Johnson finally revealed his political philosophy?,” LSE British Politics and Policy, 29 March 2021. https://blogs.lse.ac.uk/politicsandpolicy/greed-my-friends/.

[11] Luke Savage, “Bill Gates Chooses Corporate Patent Rights Over Human Lives.” Jacobin, 16 April 2021. Link to article.

[12] Stephanie Nolen, “Here’s Why Developing Countries Can Make mRNA Covid Vaccines,” New York Times, 22 October 1921; Link to article.

[13] Polydore Ngoy Mutombo, Mosoka P. Fallah, Davison Munodawafa, Ahmed Kabel, David Houeto, Tinashe Goronga, et al., “COVID-19 vaccine hesitancy in Africa: a call to action,” The Lancet, Global Health (20 December 2021), Link to Article.  

[14] A.H. Neely and T. Lopez, “Fundamentally uncaring: The differential multi-scalar impacts of Covid-19 in the US,” Social Science and Medicine 272 (2021), 113707. Link to article.

[15] Sandra Crouse Quinn,  Supriya Kumar, Vicki S. Freimuth, Donald Musa, Nestor Casteneda-Angarita, and Kelley Kidwell, “Racial Disparities in Exposure, Susceptibility, and Access to Health Care in the US H1N1 Influenza Pandemic,” American Journal of Public Health 101, 2 (2011), 285–93. DOI.

[16] William Darity and Kirsten Mullen, “Black Reparations and the Racial Wealth Gap,” Brookings (blog), 15 June 2020. Link to article; Gbenga Ogedegbe, Joseph Ravenell, Samrachana Adhikari, Mark Butler, Tiffany Cook, Fritz Francois, Eduardo Iturrate, et al. “Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients With-Covid-19 in New York City.” JAMA network open 3, no. 12 (2020), e2026881–e2026881. Link to article; Christopher T. Rentsch, Farah Kidwai-Khan, Janet P. Tate, Lesley S. Park, Joseph T. King Jr, Melissa Skanderson, Ronald G. Hauser, et al., “Patterns of Covid-19 Testing and Mortality by Race and Ethnicity among United States Veterans: A Nationwide Cohort Study.” PLOS Medicine 17, 9 (2020), e1003379, DOI.

[17] Emiliano Rodríguez Mega, “The Rise of the Mixed-Race Myth in Latin America.” Nature, Feature, 600 (December 2021); Link to article, and see also Mónica G. Moreno Figueroa and Emiko Saldívar Tanaka,  “‘We Are Not Racists, We Are Mexicans’: Privilege, Nationalism and Post-Race Ideology in Mexico.” Critical Sociology 42, 4–5 (2016): 515–33; DOI.

[18] Edward Telles, René D. Flores, and Fernando Urrea-Giraldo, “Pigmentocracies: Educational Inequality, Skin Color and Census Ethnoracial Identification in Eight Latin American Countries,” Research in Social Stratification and Mobility 40 (June 2015): 39–58. DOI.

[19] Patricia de Santana Pinho,  “Whiteness Has Come Out of the Closet and Intensified Brazil’s Reactionary Wave,” in Benjamin Junge, Sean T. Mitchell, Alvaro Jarrin, and Lucia Cantero, eds.,  Precarious Democracy: Ethnographies of Hope, Despair, and Resistance in Brazil  (New Brunswick, Camden, and Newark, N.J., and London: Rutgers University Press, 2021),  62–76.  DOI.

[20] Abril Saldaña-Tejeda, “Bioethical Guidelines of ‘Extreme Triage’ Under Covid: The Question of ‘Possible Lives’ in Latin America,” Bionatura 5, 4 (2020): 1434–37. DOI.

[21] In-person interview with “Consuelo” (a pseudonym used to protect anonymity) in 2021 by Lucia Vitale.