Syndemic

Anthropologist Merrill Singer coined the term syndemic in the early 1990s to describe the mutually reinforcing nature of health crises, such as substance abuse, violence, and AIDS, that take hold in communities with harsh and inequitable living conditions. Observers throughout history have recognized that different disease processes interact, but Singer's innovation was to interpret those connections as evidence of a higher order phenomenon, which he named a “syndemic.” A generic definition “is two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.”

Since the 1970s, health planners have understood that effective responses to the intertwined afflictions within communities require systemwide interventions. However, the desire to achieve systemic change stands in opposition to what most public health agencies are prepared to do. Ingrained in financial structures, problem-solving frameworks, statistical models, and the criteria for professional prestige is the idea, inherited from medical science, that each affliction can be prevented individually by understanding its unique causes and developing targeted interventions. Consequently, most practitioners operate with resources focused on one disease or risk factor, leaving other problems to be addressed by parallel enterprises.

Evaluations confirm that this single-issue approach can be effective in temporarily reducing the rate of a given disorder, but it cannot serve as a means for fulfilling society's ongoing interest in ensuring the conditions under which people can be healthy. The main difficulty is that an exclusively disease-focused orientation prohibits a full view of the ways in which different afflictions interact. Conceptual and analytic boundaries drawn around disease categories invite simplifying assumptions such as independence and one-way causality, as well as instantaneous and linear effects. Such assumptions make the modeling task more tractable and can produce valid insights over the short term but are eventually misleading because they fail to account for the effects of causal feedback coming from outside the chosen boundary.

Proponents of a syndemic orientation do not dispute the benefits of addressing unique problems uniquely. Rather, they acknowledge the limitations of doing so and offer a complementary approach that places multiple afflictions in context. Even as colleagues continue to address specific health problems, others operating from a syndemic orientation may devise long-range policies that engage a different set of causal processes: those that configure patterns of affliction in society. By situating unique afflictions within the dynamic systems of which they are a part, a syndemic orientation concentrates on the conditions under which people can be healthy. It questions how and why those conditions differ among groups and goes even farther to engage the struggle for directed social change.

For evaluators of health programs and policies, a syndemic orientation involves not just one but a sequence of shifts in perspective. Each view offers a conceptual and mathematical formalism that is both comprehensive and context sensitive, a combination that is notoriously difficult to achieve using conventional evaluation schemes.

The first shift in perspective involves seeing more than one problem at a time; this is the crux of the syndemic idea. Mapping connections among afflictions provides a more complete picture of the health challenge in a community. It also lays the foundation for using formal network analyses to measure the strength and structural properties of linked afflictions.

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