Syndemics

As part of its effort to identify and understand health within the intersecting frameworks of political economy and bio-social causality, the CMA approach to the study of disease is characterized by the investigation of a set of factors including biology, epidemiology, sufferer and community understandings of the disease(s) of concern, and the social, political, and economic conditions that may have contributed to the development of ill health. To help frame this "big picture" approach to the conception of diseases, critical medical anthropologists introduced the concept of "syndemic" in the mid-1990s (Singer, 1994, 1996). While biomedical understanding and practice, traditionally, have been characterized by the tendency to isolate, study, and treat diseases as if they were distinct entities that existed separate from other diseases and independent of the social contexts in which they are found, CMA, by contrast, focuses on trying to understand social and biological interconnections as they are shaped and influenced by inequalities within society. At its simplest level, and as now used by some researchers at the Centers for Disease Control and Prevention (CDC), the term syndemic refers to two or more epidemics (i.e., notable increases in the rate of specific diseases in a population), interacting synergistically with each other inside human bodies and contributing, as a result of their interaction, to excess burden of disease in a population. As Millstein (2001), the organizer of the Syndemics Prevention Network at the CDC, notes, syndemics occur when health-related problems cluster by person, place, or time. Importantly, the term syndemic refers not only to the temporal or locational co-occurrence of two or more diseases or health problems, but also to the health consequences of the biological interactions among co-present diseases. For example, researchers have found that co-infection with HIV and Mycobacterium tuberculosis (MTb) augments the immunopathology of HIV and accelerates the damaging progression of HIV disease (Ho, 1996). At the same time, studies have shown that because HIV damages human immune systems, individuals with HIV disease who are exposed to TB are more likely to develop active and rapidly progressing tuberculosis compared with those who are HIV negative. The important feature of syndemics is not just co-infection but enhanced infection due to multiple disease interactions. Importantly, beyond the notion of disease clustering in a social location or population and the biological processes of disease interaction, the term syndemic also points to the determinant importance of social conditions in disease interactions and consequences. For example, as Paul Farmer (1999, p. 13) argues, if we look at the persistence of TB in poor countries and its resurgence among the poor in industrialized countries, we find that it is impossible to understand its marked patterned occurrence— in the United States, for example, disproportionately striking those in homeless shelters and in prisons— without assessing how social forces, such as political violence and racism, come to be embodied and expressed as individual pathology (Farmer, 1999). Living in poverty increases the likelihood of exposure to the bacteria that causes TB because of overcrowding in poorly ventilated dwellings. Research in homeless shelters has shown that they are a focal point of TB transmission among the poor. Once infected, the poor are more likely to develop active TB, both because they are more likely to have multiple exposures to the TB bacteria (which may push dormant bacteria into an active state) and because they are more likely to have pre-existent immune system damage from other infections and malnutrition. Also, poverty and discrimination place the poor at a disadvantage in terms of access to diagnosis and treatment for TB, effectiveness of available treatments because of weakened immune systems, and ability to adhere to TB treatment plans because of structurally imposed residential instability and the frequency of disruptive economic and social crises in poor families. As the case of TB suggests, diseases do not exist in a social vacuum nor solely within the bodies of those they inflict, and thus their transmission and impact is never merely a biological process. Ultimately, social factors such as poverty, racism, sexism, ostracism, and structural violence may be of far greater importance than the nature of pathogens or the bodily systems they infect. A shift in focus from individual diseases to syndemics and even individual diseases in social contexts allows a more encompassing understanding of disease as far more than a clinical challenge.

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