The COVID-19 syndemic is not global: context matters.

Richard Horton recently called COVID-19 a syndemic. He aptly used this concept to describe how COVID-19 clusters with pre-existing conditions, interacts with them, and is driven by larger political, economic, and social factors.

Calling COVID-19 a global syndemic is misguided. Syndemics matter because they focus on what drives diseases to cluster and interact. What is driving coronavirus to move through the population in the USA and interact with biological and social factors, however, differs from other contexts. US political failures have driven COVID-19 morbidity and mortality, and this cannot be divorced from our historical legacy of systemic racism or our crisis of political leadership.

This matters because in other contexts COVID-19 is not syndemic. New Zealand's political leadership in response to the crisis has been exemplary. COVID-19 is not syndemic there.

In this sense, syndemics allow us to recognise how political and social factors drive, perpetuate, or worsen the emergence and clustering of diseases.

Recognising contexts are different matters a great deal. For instance, contexts throughout sub-Saharan Africa are doing much better than the most burdened contexts, like the USA, Brazil, and India. Many people have questioned, why? Some have argued that this reflects a racist frame thinking that African contexts should suffer more. Yet, many African governments acted more swiftly and confidently than wealthier countries. The political leadership in these contexts, therefore, prevented the extensive death tolls, compared to contexts like the UK and the USA, where political leadership failed.

Recognising political determinants of health is central to the syndemic construct. By calling the COVID-19 syndemic global, we miss the point of the concept entirely.

I do not write this to dampen Horton's use of the term, as I believe COVID-19 is syndemic in my country (the USA). This is precisely because pre-existing conditions such as hypertension, diabetes, respiratory disorders, systemic racism, mistrust in science and leadership, and a fragmented health-care system have driven the spread and interacted with the virus. These synergistic failures have caused more death and devastation than many other contexts.

Recognising failures of wealthy countries is imperative as we think about where global knowledge and power sit within fields like global health. Syndemic frames provide us with an opportunity to do this.