How can philanthropy confront the harsh syndemic we face today? Yes, I wrote syndemic, not pandemic. The Lancet, one of the world’s leading medical journals, describes a syndemic as “characterised by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes.” In other words, being poor, hungry, homeless, and/or suffering from a condition such as heart disease, obesity or diabetes, makes your experience of a virus such as COVID-19 much worse. So, if you tackle the conditions affecting vulnerable populations, you lessen the impact of the virus enormously. As noted by The Lancet, “the economic crisis that is advancing towards us will not be solved by a drug or a vaccine… Approaching COVID-19 as a syndemic will invite a larger vision, one encompassing education, employment, housing, food, and environment.”
What does philanthropy have to do with this? A good deal. Foundations, as I have often argued, can be key players in systemic change. Philanthropy can work upstream to change the systems that create social and economic conditions for ill health. The de Beaumont Foundation, a US private foundation that focuses on the social determinants of health, noted in a 2019 blog that “increasing health care costs and worsening life expectancy are the results of a frayed social safety net, economic and housing instability, racism and other forms of discrimination, educational disparities, inadequate nutrition, and risks within the physical environment. These factors affect our health long before the health care system ever gets involved.”
De Beaumont Foundation uses the metaphor of the stream as a way to think about how to intervene on health issues. It’s a metaphor that applies to other social challenges as well. Downstream are the medical interventions that treat illness. Midstream are the social interventions such as social workers and community health workers who work on connecting individuals to various supports (housing, child care, skills training, food security etc). Upstream are the interventions that change conditions in communities, including public policies, government actions and community-level collaboration. The upstream interventions over the long term will certainly improve the health and social consequences far downstream.
If we think about what we are experiencing today as a syndemic, what does this imply for how foundations rethink their strategies? Many Canadian foundations were using a mix of strategies before the arrival of COVID-19. The majority probably focus downstream on responding to urgent community needs for food, shelter, medical treatment, skills training, and supports for families and youth. The immediate consequences of the virus have been a sharpening of these needs and a corresponding increase in demand for philanthropic support. Depression, anxiety, loneliness are probably more urgent mental health needs than ever, for example. Does this mean that all resources should be allocated to downstream work?
I think there is a case to be made for swimming upstream. The syndemic perspective underlines the importance of not abandoning efforts at systemic change. And there are many strategies, usually employed in a portfolio, that Canadian foundations can employ to pursue change. In 2018, FSG, the US-based consultants who work on social impact strategies, issued a useful guide that listed nine strategies for foundations wanting to work upstream:
In practice, foundations use a mix of strategies, including supporting community programs, generating knowledge (sometimes to inform policy), catalyzing collaboration, and building capacity. More foundations are practicing the convening of communities of interest and of peers and considering collective funding tools.
Since the beginning of the crisis, we have seen many Canadian foundations deploying these strategies and working upstream:
These are all remarkable examples of foundations swimming upstream to address the inevitable changes to systems that we need to cope with and to prevent the worst consequences of a future syndemic. Let’s face it, it’s on the horizon if we think about climate change, let alone another virus.