Overview Menu History Principles Uses Advantages & Limits Planning & Evaluation Trends Areas For Exploration Scientific and Social Change References

Syndemics Overview - What Are the Advantages and Limitations of a Syndemic Orientation?

At this early stage of development, it is difficult to predict what advantages and limitations will be found by adopting a syndemic orientation. Network members will discover and negotiate those over time. Part of the promise inherent in a syndemic orientation, however, lies in its ability to provide a mandate for

• disrupting forces that cause multiple health-related problems to cluster 
• repairing fragmentation of the infrastructure needed to protect the public’s health
• expanding research and action agendas by by more explicitly linking health and social justice
• introducing new methods of analysis and synthesis
• establishing a science base for a “public health bill of rights”

Advantages like these might accrue in the long term, after a syndemic orientation has matured and become institutionalized. Possible benefits closer to the horizon include enhanced collaboration within the public health sector, closer ties between public health and other sectors of society, stronger relationships between citizen leaders and health professionals, and closer connection between public health and social justice. The sections below provide a brief rationale for each of these benefits.

Enhanced Collaboration Within the Public Health Sector 
Acceptance of a syndemic orientation will almost certainly provide a catalyst for renewed collaboration throughout the public health system and beyond. As long as the most valued outcomes of prevention are measured as reductions in specific diseases, at present, practitioners have little incentive to collaborate across program boundaries to improve the public's health. This deprives prevention science of the energy that is unleashed through collaboration, while also fueling inefficiency and bureaucratic frustration.

The usual incentives for prevention programs reward organizations when their programs (a) receive notoriety, (b) survive over time, (c) get more money, or (d) produce results that are directly attributable to planned actions. These are significant achievements, but they are insufficient for guiding program and policy development at the population level. Without additional incentives for broader collaboration, a community could have many effective programs but still have people who are becoming no healthier.

Imagine, for example, a neighborhood with effective programs under way for preventing heart disease, cancer, HIV, tuberculosis, influenza, asthma, and lead poisoning but extraordinarily high rates of depression, alcoholism, homicide, and foodborne illness. For health to get better in a practical sense, the major interconnecting causes of morbidity and mortality must be identified and addressed simultaneously. Under a syndemic orientation it might be possible to organize a wide range of actors, who could be held accountable and rewarded for improving health status and health equity in the area. Nothing less fulfills the mission of public health work.

Closer Ties Between Public Health and Other Sectors of Society 
Stronger links among public health organizations are imperative, but the work cannot stop there. Natural partners in the effort to prevent syndemics must also be sought outside the formal public health system. Using research and evidence from experience as a guide, advocates of a “theory of change” approach are identifying pathways through which actions taken in "non-health" sectors eventually affect health. Indeed, past research has shown that some of the strongest predictors of health status are social determinants, including employment, social equity, and early childhood development. (Wilkinson and Marmot, 1998).

Changing determinants of health that are not controlled by authorities within the health sector requires coalitions that reach beyond the confines of familiar partnerships. Working from a position of solidarity with community members, agency leaders will be called upon to align their actions with relevant organizations all along the identified pathways of influence, regardless of how far afield from classical public health they reach. Mapping those pathways is analogous to mapping the human genome, a grand challenge that promises to be as beneficial in propelling the development of public health science as the Human Genome Mapping Project has been for molecular biology (Schorr, 1997). Some forces other than public health that might emerge as having strong ties to health status and health equity are listed in Table 2.

Table 2: Selected Forces Outside of Public Health That Affect Health Status and Health Equity

• Addiction services (prevention, treatment)
• Agriculture
• Architecture 
• Economy (labor, management, commerce, fiscal policy)
• Education
• Energy 
• Entertainment 
• Environment (land, air, water, biodiversity, atmosphere, light, temperature)
• Faith 
• Governance (local, state, federal, international)
• Hospitality
• Housing
• Human service (child care, welfare, health care)
• Information (journalism, media)
• International relations
• Justice (law enforcement, public safety, civil rights, human rights)
• Land use (regional planning, urban design)
• Mental health
• Philanthropy
• Recreation (sports, arts, humanities)
• Security (defense)
• Science and technology (research and development)
• Transportation

Fortunately, the importance of forming inclusive partnerships to protect the public's health is becoming more widely understood. In fact, efforts are already under way to position public health services as shared responsibilities of an entire system of organizations working in partnership with their constituents, and not just governmental health departments (NACCHO, 2001). This work is essential for building society's organizational capacity to understand and prevent both epidemics and syndemics.

Stronger Relationships Between Citizen Leaders and Health Professionals 
When forging partnerships, it is also important to strengthen the relationship between citizen leaders and health professionals. These stakeholders need each other, but they often approach their work using different frames of reference, with different values and standards for success.

One persistent source of tension between the two groups centers on how to define the proper scope for health improvement projects.  Because resources are almost always allocated to specific health problems, professionals often try to keep the scope as narrow as possible, believing, that this will enhance the chances of demonstrating attributable effects. Citizen leaders tend toward a different view. Aware of their neighborhood's history and concerns, they are better able to place problems in context and consider them as a group. This approach generally leads them to conclude that comprehensive change (often at a systems level) is the more sensible strategy. The alternative--addressing specific instances of a systemic problem--to them is like treating symptoms instead of the disease.

Under many scientific frameworks, the tension between categorical and comprehensive approaches has been notoriously difficult to resolve. Frequently, resolution means sacrificing either the project's evaluability (because the program becomes too diffuse and unstable) or its chances of achieving meaningful results (because there is a focus on small problems and not the big picture) (see Schorr, 1997). A syndemic orientation offers a better way to resolve the dilemma.

The practical advantage of a syndemic orientation can be seen with a network diagram (Figure 4). The nodes represent diseases, and the edges represent ties, or forces that cause the diseases to concentrate by person, place, or time. Professionals, trained as disease specialists, focus mainly on the nodes. While citizen leaders, steeped in neighborhood context, tend to focus on the ties. Beyond the diseases themselves, citizen advocates see forces that hold the entire constellation of disorders together. Those connecting forces can be as much of a problem as the diseases themselves. Sometimes they are even more so, because it is logical to assume that the overall structure of disease in the area will persist unless those connecting forces are addressed. 

Figure 4: A Syndemic Network

The views of health professionals and citizen leaders deserve respect and dignity because each fills in a critical part of the puzzle. With this foundation, health professionals and members of the public could develop a common language and forge a closer, more authentic connection in their work. With a syndemic network in mind, planners can devise ways of weakening diseases at the nodes while simultaneously disrupting ties that allow those diseases to accumulate into an unwieldy burden for the population. Together these strategies set the stage for effective collaboration at a scale that better matches the complexity of transforming adverse living conditions and systems.

Closer Connection Between Public Health and Social Justice 
A syndemic orientation can also advance a specific course of social change, one focused on the connection between health and social justice. Public health professionals who operate under a syndemic orientation would have a stronger incentive to collaborate with community members in understanding the entire set of forces that create excess burden of disease. By examining epidemics in context and seeing syndemics where they exist, health scientists might begin to identify a different set of risk and protective factors and mobilize to change them. In all probability these factors would include those that human rights advocates see as fundamental to their work (i.e., education, justice, economic opportunity, housing, environmental protection, self-determination, social cohesion, peace, and so forth).

Under a syndemic orientation, alliances might be strengthened between sectors of society, thereby creating a more powerful mandate for directed social change. Ultimately, the analyses conducted using a syndemic orientation could provide the science base for a public health bill of rights. Such a document might better define the conditions that all human groups deserve and should expect so as to create and sustain maximal health, quality of life, and social justice.

Limitations 
As progress in exploring syndemics continues, there will also be problems to avoid. Pitfalls are inherent in introducing an unfamiliar term, defining practical boundaries for networks within networks, building trust among groups with a history of weak collaboration, and engaging those who have been previously excluded from decisions about public health science and action. Although the challenges facing proponents of a syndemic orientation are considerable, they must be weighed against known limitations of maintaining the status quo. By that standard, there is a clear mandate to explore all perspectives that may yield viable alternatives.

Next: What Procedures Are Available for Planning and Evaluating Initiatives to Prevent Syndemics? >>

Back to top

References

National Association of City and County Health Officials.  Mobilizing for Action Through Planning and Partnerships (MAPP).  Washington, DC: National Association of City and County Health Officials, 2001
HTML

Schorr LB. Common purpose: strengthening families and neighborhoods to rebuild America. New York, NY: Doubleday, Anchor Books, 1997.
HTML

Wilkinson R, Marmot M.  The solid facts: social determinants of health.  Copenhagen: World Health Organization, 1998
HTML or PDF (3.1 MB)
 

Page last reviewed: January 30, 2008
Page last modified: January 30, 2008

Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion