Syndemic Prevention Network: Monograph -- Prologue

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Centers for Disease Control and Prevention

Prologue

Life expectancy in America was still lengthening between 1993 and 2006, as it had for most of the 20^th century (Bell, 2005; National Center for Health Statistics, 2006). However, during that same period, adults in the United States reported a sharp decline in health-related quality of life, indicated by a 17% increase in the average number of unhealthy days per month (Figure 1) (Zack, Moriarty, Stroup, et.al., 2004). An important challenge for the modern health protection system¹ is to reconcile these apparent differences.

Figure 1: Worsening Trend in Adult Unhealthy Days,
United States 1993–2006

Part of the reason is because health problems within populations almost never exist independently of one another. For instance, people at risk for one affliction (e.g., diabetes) tend to be at risk for many (e.g., obesity, heart disease, cancer, asthma, depression), and those afflictions are often mutually-reinforcing. Because of those interconnections, it is necessary to address the particular features of each disease while also crafting conditions that free people from becoming vulnerable to such massively entangled health threats in the first place. To sustain improvements in overall health and safety, public health work cannot stop with the delivery of effective disease prevention services; indeed that is just the beginning.

Health planners have understood for decades that effective responses to the intertwined afflictions in populations require system-wide interventions. But the desire to achieve systemic change stands in opposition to what most health agencies–and the people who lead them–are prepared to do. Ingrained in financial structures, problem-solving frameworks, statistical models, and the criteria for professional prestige is the idea that each affliction can be prevented individually by understanding its unique causes and developing targeted interventions. Evaluations confirm that this single-issue approach can be effective in reducing temporarily the rate of a given disorder, but it cannot serve as a means for fulfilling society’s ongoing interest in assuring the conditions in which all people can be healthy (Institute of Medicine, 1988, 2002a). Nevertheless, most health protection ventures operate with resources focused on one disease or risk factor, leaving other problems to be addressed by parallel efforts. This important, but ultimately insufficient, categorical approach is now so entrenched that the health protection system itself has been diagnosed with a disorder known as “hardening of the categories” (Wiesner, 1993:196).

In 1992, a new conversation became possible with the introduction of an unfamiliar word. Anthropologist Merrill Singer coined the term syndemic to describe the mutually reinforcing nature of health crises such as substance abuse, violence, and AIDS that take hold among people facing harsh and inequitable living conditions (Singer, 1994, 1996; Singer and Clair, 2003; Singer and Snipes, 1992). Observers throughout history have recognized that different disease processes interact in populations, much as they do within individuals, but Singer’s innovation was to interpret those connections as evidence of a higher-order phenomenon, which he and his colleagues called a syndemic.

The science of epidemiology was invented in the 19^th century to understand and control discrete, sporadically occurring, and widespread health problems–and it has proven to be an indispensable tool for guiding certain aspects of public health work. The notion of a syndemic, by contrast, challenges us to develop a complementary science of relationships, one that is capable of better understanding and more effectively governing the dynamic forces that surround multiple health problems, as well as the intricate organizational systems that we as a society create to anticipate and respond to them.

This report explores how the seemingly subtle distinction between a single epidemic and the phenomenon of syndemics expands, in very particular ways, the conceptual, methodological, and moral dimensions of public health work. At a time when even the most highly trained and seasoned health professionals are beset–and frequently bewildered–by the sheer number of threats that they are called upon to address, the prospect of thinking in syndemic terms has become a pragmatic imperative. It is a reminder that epidemiologic principles have been applied largely to the first tier of a highly complicated health system, as well as a call for orienting the entire health protection enterprise in new directions.

Striving to transform the conditions that give rise to syndemics, many health leaders are working harder than ever to reduce aggregate and inequitable burdens of illness in whole populations. Such comprehensive undertakings elevate public health work to new heights of ambition and complexity. Acting at this system-wide scale, however, requires thinking differently about public health work itself. As a result, innovators throughout the field are observing the health protection system in novel ways, exploring new frameworks for understanding the forces of change, adhering to new principles for directing the course of change, and devising new techniques for charting progress (Leischow and Milstein, 2006).

Intrigued by these innovations and intent on understanding more precisely what a syndemic orientation entails, the Centers for Disease Control and Prevention (CDC) created the Syndemics Prevention Network. Launched in November 2001 (Milstein, 2002b), the group tracks particular instances in which syndemic principles are used, while at the same time pursuing broad, exploratory questions about the pressures and opportunities that move the field to rework its boundaries and practices, and even its language. In that regard, the project recognizes that public health work has changed significantly since its formalization in the mid-19^th century and that even today it is poised for further transformation. With this long view on the evolution of public health ideas, combined with a special emphasis on those innovations, trends, and priorities that have emerged in the modern era (1970–present), it is apparent how profoundly the field is changing. Three clearly discernable directions capture what is in fact a vast and highly nuanced set of shifts. Modern public health work is becoming more

Interconnected (i.e., ecological, multi-causal, dynamic, systems-oriented): efforts focus increasingly on exerting leverage within a large, evolving system rather than on controlling its discrete parts in their strictest sense (i.e., as parts unto themselves).

Public (i.e., broad-based, partner-oriented, citizen-led, inter-sectoral, transparent, democratic): actors are increasingly concerned with respecting many interests and assuring mutual-accountability as opposed to serving the needs and interests of any particular group or hierarchical authority.

Questioning (i.e., evaluative, reflexive, critical, ethical, pragmatic): standards for judgement tend to examine how simultaneous values like health, dignity, security, equity, satisfaction, justice, prosperity, freedom and others are upheld in both means and ends.

This report goes beneath these emerging directions. By situating the recent dialogue about syndemics within the broader trajectory of ideas about public health practice, we examine what these movements imply, individually and collectively, about the changing character of modern public health work.

1. Highlighted terms are discussed further in the glossary.

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