Elsevier

The Lancet

Volume 389, Issue 10072, 4–10 March 2017, Pages 941-950
The Lancet

Series
Syndemics and the biosocial conception of health

https://doi.org/10.1016/S0140-6736(17)30003-XGet rights and content

Summary

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Section snippets

The nature of syndemics

Co-infection with multiple pathogens, as Laurent Hébert-Dufresnea and Benjamin Althousea1 have emphasised, can be a critical factor in disease course and outcome. Concurrent infection, as described for infectious agents such as HIV and Mycobacterium tuberculosis, for example, is associated with more rapid disease progression, worse symptoms, and higher pathogenic load than during a single infection with either agent.2, 3 In addition to HIV accelerating advancement from latent to active

Syndemics research

The first syndemic identified and described in the literature,13 and the one most heavily investigated, is known as SAVA (substance abuse, violence, and AIDS). This term describes three closely linked and interdependent conditions that coexist in the human body and social life of many individuals in low-income urban environments.13 Recognition of this syndemic emerged during a multiyear research programme on HIV risk prevention among drug users, in which researchers realised that the

Syndemic pathways

A core concern of syndemics research is the investigation of the specific pathways through which disease and other health conditions interact in the body and within populations to allow multiplication of adverse health effects. Domains of social–psychological, psychological–biological, and social–biological interaction are as fundamental to syndemics as biological interactions are. Syndemics are not characterised merely by co-occurring conditions, but rather exemplify the nature of the changes

Syndemics and mental health

No less than physical diseases, alterations of the emotions and of mental health, for example by trauma, stress, internalisation of social rejection, and the embodied experience of social stigma, can have a role in the onset and exacerbation of other diseases, including somatoform diseases. The internalisation of social contempt opprobrium through a stigmatised illness or disease-related, stigmatised identity can have both psychosocial and biological effects on disease–disease interaction and

Clinical issues

Awareness of syndemics raises important questions from a biomedical perspective. How do syndemic interactions complicate diagnosis? What is the best course of medical treatment for entwined syndemic diseases? How could clinicians address the social causes of syndemics? How can iatrogenic syndemics in biomedicine be avoided? Can counter-syndemics play an innovative part in new treatment options?

An important complication of syndemics is that they can alter landmark disease characteristics that

The social origins of syndemics

Broadening biomedical care to consider not only the biological but also the social components of disease is an inherent part of the syndemics perspective. Farmer and colleagues56, 57 at Partners in Health have shown that structural interventions within the biomedical setting can have a greater impact than conventional clinical interventions on disease control. Using their model in Haiti, Peru, Rwanda, Lesotho, Boston (MA, USA), and elsewhere, Partners in Health have: removed clinical and

Syndemics, multicausal models, and health policy

The syndemics orientation has the potential to affect health policy by drawing attention to how social, economic, and environmental factors affect the health of human beings, provided that these factors are not separated in analysis from disease emergence or comorbidity. Instead, the clustering of diseases and the vulnerability of populations to disease must be recognised to incorporate inherent social and environmental risk factors. Doing so becomes an ever more pressing issue as populations

Programmatic initiatives

Approaches to health promotion that are appropriate from a syndemics perspective have been implemented at the national level in various countries through progressive social policies aimed at poverty alleviation and inequality reductions. Such initiatives operate through multiple mechanisms, in line with the syndemic perspective: improving social conditions by decreasing poverty and barriers to health care; improving food access and education; and providing health-care access and biomedical

Conclusion

As emphasised by Littleton and Park,71 a syndemics approach to disease is valuable because of the degree to which disease comorbidity and noxious social conditions are concentrated together in populations. Syndemics underline the importance of the disease clustering within populations, the social, psychological, and biological reasons that diseases cluster, the ways comorbid diseases affect each other, how important these interactions can be to the health burden within the populations, the

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