STIA Professor Emily Mendenhall Launches Series on Syndemics in The Lancet Medical Journal

April 4, 2017
by Margaux Fontaine

Dr. Emily Mendenhall, an Assistant Professor of Global Health in the Science, Technology, and International Affairs (STIA) Program in the School of Foreign Service, hosted a panel on a series of papers she co-authored in The Lancet medical journal about syndemics. A combination of “synergy” and “epidemic,” syndemics is an innovative concept that stresses the importance of looking beyond purely medical factors to see how diseases come together through macro-social forces, offering a different framework for thinking about and reacting to health and healthcare inequities. The series can be read here.

At the panel, Mendenhall was joined by Dr. Brandon Kohrt, an Assistant Professor of Psychiatry, Global Health, and Cultural Anthropology at Duke University. Other co-authors Dr. Sarah S. Willen, Assistant Professor of Anthropology at the University of Connecticut and Director of the Research Program on Global Health and Human Rights at UConn’s Human Rights Institute; Dr. Alexander Tsai, a board-certified psychiatrist at the Massachusetts General Hospital, Associate Director for Trainee Development in the Chester M. Pierce, MD Division of Global Psychiatry; and Dr. Merrill Singer, a medical anthropologist and professor in Anthropology at The University of Connecticut and in Community Medicine at The University of Connecticut Health Center, joined the conversation via video.

Syndemics looks at three key features: the clustering of two or more diseases, biological, social, or psychological interactions, and large scale social forces that precipitate these interactions and clusterings. In contrast with the frameworks of comorbidity, syndemics stresses the importance of social and economic forces, putting them on on equal footing to disease in causing morbidity and mortality.

“So while comorbidity and multimorbidity recognize two conditions that arise concurrently – or, in the case of comorbidity, may interact and affect one another – a syndemic recognizes how diseases that converge among socially and economically disadvantaged populations do not do so in isolation,” Mendenhall said. “Instead, their convergence is socially, politically, and economically motivated.”

The concept of syndemics originated in the 1990s with Singer’s field research with injection drug users in Connecticut, which looked at the social context faced by these drug users. The prevalences of disease clustering was significant.

“We heard many accounts of people not only having HIV … but a whole slew of other diseases, and multiple diseases,” Singer explained. “And it began to raise the question for us: what is the consequence of having multiple diseases at the same time?”
They then started to zero in on the social conditions that make populations more vulnerable – for example, high levels of stress can lead to a weakened immune system, and can cause diseases to interact in adverse ways. It was within this intersection that the concept of syndemics was born.

“We began to shape an understanding that we really couldn’t talk about HIV in this population separate from a discussion of violence, separate from a discussion of drugs – that really these all form one complex that needs to be talked about together,” Singer said.

A highly multidisciplinary field, syndemics looks beyond disease pathology and considers the role of environmental factors – even looking at the impact of climate change on vulnerable populations.

Tsai spoke about syndemics from the perspective of population health, discussing the potential applications the syndemic framework could have for medical intervention and policy, and more specifically about the importance of testing disease interaction.

“In order to move the field forward, what we recommend in this paper is multi-method studies that involve anthropology, as well as simulations, as well as epidemiology,” Tsai said.

Willen discussed the application of syndemics on health and human rights, looking at the syndemic vulnerabilities of particularly at-risk groups such as migrants and refugees.

“Where the syndemics approach is often lacking these days, and what the health and human rights framework can offer, is a set of concrete tools, mechanisms, and strategies for holding states and leaders accountable,” Willen explained.

Kohrt looks at the application of syndemics in global public health. As a practicing psychiatrist, he has observed that comorbidity is often the rule rather than the exception at the individual level. Syndemics can offer a new and beneficial framework for treatment.

“From an anthropological level, I think the important thing to remember is that, to some degree, suffering is suffering,” Kohrt said. “If we design care systems more around the idea of alleviating suffering as a whole, as opposed to just targeting specific disorders, that in and of itself with help to address the multi-component view.”

In closing, Mendenhall explained the important applications of syndemics in looking not only at the presence of more than one health condition, but also on the contextual factors that contribute to this clustering.

“There are important global health shifts in how we think about disease and suffering, and by looking at these clusters we can more productively think about where we should spend our money,” Mendenhall said. “We have a lot of evidence to show what can make a really impact in people’s lives.”