The idea of structural violence is premised, in part, on Wallace's analysis of the multiple layers of societal and structural factors that place individuals at risk for HIV (Wallace, 1988, 1990). Capturing a wider trend in urban areas with systemic implications for poverty and health, Wallace recounts how urban deterioration in the Bronx, loss of municipal and public health sector funds, in conjunction with widespread fires, combined to result in an environment conducive to the rapid spread of HIV. Singer (1994) first described what he termed "syndemics" of the urban poor. Syndemics, fully explained by Baer, Singer, and Susser (1997) below, are intertwined and mutually reinforcing health issues and social conditions of the urban poor:
Health in the inner-city is a product of a particular set of closely interrelated endemic and epidemic diseases, all of which are strongly influenced by a broader set of political-economic and social factors, including high rates of unemployment, poverty, homelessness, and residential overcrowding, substandard nutrition, environmental toxins, and related health risks, infrastructural deterioration and loss of housing stock, forced geographic mobility, family breakup and disruption of social support networks, youth gangs and drug-related violence, and health care inequality. (Baer et al., 1997, p. 174)
Singer illustrated this idea by describing the substance abuse, violence, and AIDS (SAVA) syndemic, a constellation of experiences, symptoms, and behaviors among study participants that appeared to be synergisti-cally linked: substance use, experience of abuse or violence, and current infection with HIV/AIDS.
The concept of syndemics is useful for understanding how sociocultural, historical, and geographic realities in urban areas interact with and compound the adverse consequences of disease. Fullilove, Green, & Fullilove, (1999a) describe the inevitable increase of violence, addictive disorders, and HIV rates in urban U.S. areas following the high unemployment rates, increase in drug trade, and urban flight of the 1970s and 1980s. Similarly, the forced migration of rural dwellers to urban areas in large parts of Africa, Latin America, and Asia subsequent to loss of viable work, economic development programs, and political flux has resulted in overcrowding, challenges to already inadequate infrastructures, and the rapid transmission of HIV in parts of Africa, South America, and Asia (Farmer et al., 1995; Parker, 1995; Romero-Daza & Himmelgreen, 1998; Sabatier, 1996). The lack of basic sanitation alone in squatter settlements that surround large cities in as much as 20-50% of the developing world (Rubenstein & Lane, 1990) is a considerable barrier to health and overall survival. Dehydration from diarrheal disease, for example, is a direct result of inadequate sanitation and contaminated water supply sources. Feasible and sustainable interventions for reducing rates of infectious disease among the urban poor must be geared not only toward individual behavior, but toward the reality of the multiple and concurrent health threats in impoverished urban areas and the systemic, structural, and institutional components of disease (Manderson, 1998).
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