How we think about disease pathologies affects how we package policies and deliver care for those most affected by social and economic inequities. By overlooking social, political and ecological factors, current frameworks in medicine and public health often fail to address the complex and multifaceted variables impacting disease pathology. In a recent series of papers published in the Lancet medical journal, medical anthropologists offer an innovative alternative: syndemics.
These papers were led by Professor Emily Mendenhall from the Walsh School of Foreign Service who teaches in the Science, Technology, and International Affairs (STIA) Program. Mendenhall explains that the concept of syndemic — which combines notions of “synergy” with epidemic” — exemplifies a “STIA” problem because it brings together science with politics.
“The concept of syndemics stresses the importance of looking beyond 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,” Mendenhall explained. As opposed to the notion of epidemic, which marks the distribution of a disease across a population, the notion of syndemic incorporates three core concepts: 1) two or more diseases cluster together within a population, 2) these diseases interact, often biologically, and 3) large-scale social forces give rise to them. This is important because rarely does an epidemic work in isolation across a population, especially when it encounters poverty, social exclusion, gender-based violence, climate change, displacement to agricultural or industrial waste, and other forms of social and environmental stress.
“In many cases, the convergence of social and health conditions encumber social lives, complicate one or more diseases, and unequivocally shape illness experiences and worsen health outcomes,” Mendenhall explains. One example is syndemic clustering of HIV and tuberculosis: the diseases interact biologically insofar as HIV leaves the immune system more vulnerable to viruses such as tuberculosis; the diseases interact on a social level as well, thorough structural vulnerabilities such as living in close quarters and poor healthcare access. Mendenhall states, “Without recognizing how social and structural factors promote disease clustering like HIV and tuberculosis, efforts to understand their extraordinary impact on impoverished populations and design social policies and integrative medicine to address them fall short.”
Mendenhall’s previous research has primarily focused on the social, psychological, and biological factors in conditions occurring alongside Type 2 diabetes. She wrote the first full-length book on any singular syndemic, entitled Syndemic Suffering: Social Distress, Depression, and Diabetes among Mexican Immigrant Women; this work considers the effects of poverty, immigration, and interpersonal violence on depression and Type 2 diabetes.She has another book in revision that brings together her ethnographic research on diabetes, trauma, poverty, and AIDS from urban communities in the United States, India, Kenya, and South Africa.
Mendenhall explained, “Co-occurring depression and diabetes does not always result in adverse health outcomes. Rather, poverty, social trauma, and limited access to health care exacerbate biological interactions of and resultant adverse outcomes to syndemic diabetes with chronic, untreated depression.”
These effects are amplified in populations facing extreme vulnerabilities, such as refugees or unauthorized migrants, or groups facing poverty or gender-based violence. Delayed medical attention can contribute to undiagnosed disorders, often resulting in escalated medical and social problems.
Mendenhall continued to explain the policy-relevance of using “syndemics” to understand ill health of impoverished communities. “By recognizing syndemic clusters, policies that improve education and housing conditions, enhance social cohesion, and provide more community-based support could plausibly enhance health outcomes for diseases that syndemically interact. This makes a big impact especially when similar forces — like wealth inequality or persistent financial or food insecurity — serve as motivators of more than one condition.”
The papers also detail the approach described as “syndemic care,” in which health systems focus on providing holistic medical care as opposed to care focused on singular disease outcomes. Mendenhall describes how “This ideology aligns closely with Georgetown’s values of addressing whole persons and thinking about how multiple factors affect people in the world.” She explains that one important vehicle for achieving holistic medical care is integrating community health or social workers into clinical visits. Adding the social element into clinical care can improve patient outcomes by recognizing the underlying social, economic, and psychological factors impede treatment. It also incorporates diagnostics and routine care into one medical visit, saving the patient time and money.
Recognition of syndemics promotes the need to build strong health systems that are accessible, affordable, and available for vulnerable populations worldwide. Mendenhall adds that, “by addressing the social and economic drivers of health inequities, we can radically transform the distribution of suffering and ill health globally as well as in the U.S.”