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Syndemics Overview - History: What is a Syndemic?

"Syndemic" is a term invented to describe a set of linked health problems. Prior to 2001, the word did not appear in any dictionary.  The following working definition conveys the meaning usually understood by those who have studied the concept:  

A syndemic is two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.

Syndemics occur when health-related problems cluster by person, place, or time.  The problems-along with the reasons for their clustering-define a syndemic and differentiate one from another (although as in most network structures they may have nested or overlapping relationships) (Figure 1).  To prevent a syndemic, one must prevent or control not only each affliction but also the forces that tie those afflictions together. 

Figure 1: A Syndemic Network

The first syndemic to have been named and analyzed in the professional public health literature was reported by Merrill Singer.  Comprised of substance abuse, violence, and AIDS, the “SAVA” syndemic conveyed what he saw as inextricable and mutually reinforcing connections between three conditions that disproportionately afflict those living in poverty in U.S. cities (Figure 2; Singer 1994; 1996). The following passages explain why Singer and his colleagues introduced the term:

"Commonly, violence, substance abuse, and AIDS have been described as concurrent epidemics among inner-city populations. However, the term epidemic fails to adequately describe the true nature of the contemporary inner city health crisis, which is characterized by a set of closely interrelated, endemic and epidemic conditions, all of which are strongly influenced by a broader array of political-economic and social factors, including high rates of unemployment, poverty, homelessness and residential overcrowding, substandard nutrition, infrastructural deterioration and loss of quality housing stock, forced geographic mobility, family breakup and disruption of social support networks, youth gang formation, and health care inequality (Wallace R, 1988; 1990; Wallace D, 1990).

We have introduced the term "syndemic" (Singer M, 1994) to refer to the set of synergistic or intertwined and mutual [sic] enhancing health and social problems facing the urban poor.  Violence, substance abuse, and AIDS, in this sense, are not concurrent in that they are not completely separable phenomena. Rather, they emerge in the lives of participants in our study as closely intertwined threads in the often tattered fabric of their daily lives" (From Singer M, Romero-Daza N, 1997).

Figure 2 The SAVA Syndemic**

** Adapted from Singer M, 1996

The notion that syndemics are a distinct phenomenon is a logical progression from the work that Rodrick and Deborah Wallace had been doing on the "synergism of plagues" (Wallace R, 1988; Wallace R, Wallace D, 1997; Wallace D, Wallace R, 1998).  The particular synergism at the center of their research arose in New York City after implementing a 1969 public policy known as "planned shrinkage" (i.e., deliberately withdrawing municipal resources from selected neighborhoods to free up land and funds for alternative uses).  By combining methodologies from epidemiology and ecology, the Wallaces and their colleagues have documented "a self-reinforcing, interactive mix of contagious urban decay and deterioration in both public health and public order" after fire services were removed and rearranged under the policy of planned shrinkage (Wallace R, Wallace D, 1997).  The following passage describes how in the aftermath of this policy several "separate" diseases were in fact tied together, ultimately limiting life expectancy for those most heavily afflicted.

"Many poor neighborhoods simply collapsed...the South Central Bronx, for example, lost 80% of both housing units and population between 1970 and 1980.  About 1.3 million white people left New York as conditions deteriorated from housing overcrowding and social disruption.  About 0.6 million poor people were displaced and had to move as their homes were destroyed.  A total of almost 2 million people were uprooted, over 10% of the population of the entire Standard Metropolitan Statistical Area...Out of the overcrowding and the social unraveling of the community came epidemics of contagious disease and contagious behavior problems both in the remnants of the burned out neighborhoods and in the newly crowded neighborhoods receiving refugees: tuberculosis, measles, substance abuse, AIDS, low-weight births, and violence.  Life expectancy of elderly blacks declined from 1970 to 1980 after decades of increase and in contrast to that of elderly whites which increased uninterruptedly."  (From: Wallace D, Wallace R, 1998. page xvi).

A close reading of public health history reveals that many people have understood the attributes of syndemics without using this term.  Insightful citizen leaders, social and behavioral scientists, health educators and others have a tradition of addressing connections between health problems and even between health and social problems. Yet, their work at the population level has been criticized for falling outside the limits of accepted frameworks grounded in the categorical assumptions of formal public health science.

The conceptualization of a syndemic is significant because it expands the boundaries of public health science and action. The prospect of organizing resources around a syndemic orientation joins the science of epidemiology with the action agenda of citizen leaders, yielding a framework that can guide initiatives of greater size and complexity than ever before. This perspective complements single-issue prevention strategies that may be effective in controlling discrete problems but often are mismatched to the goal of protecting the public's health in its widest sense.

Next: What Principles Characterize a Syndemic Orientation? >>

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References

Singer M. AIDS and the health crisis of the US urban poor: the perspective of critical medical anthropology. Social Science and Medicine 1994;39(7):931-48.

Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inquiry 1996;24(2):99-110.

Singer M, Romero-Daza N. A notable connection between substance abuse, violence, and AIDS: initial findings from research in the Puerto Rican community of Hartford. Hispanic Health Council: Hartford, CT. 1997.

Wallace D. Roots of increased health care inequality in New York. Social Science and Medicine 1990;31(11):1219-1227.

Wallace R. A synergism of plagues. Environment Research 1988;47:1-33. 

Wallace R. Urban desertification, public health and public order: planned shrinkage, violent death, substance abuse and AIDS in the Bronx. Social Science & Medicine 1990;31: 801-813.

Wallace R, Wallace D. Resilience and persistence of the synergism of plagues: stochastic resonance and the ecology of disease, disorder and disinvestment in US urban neighborhoods. Environment and Planning A 1997;29(5):789-804. HTML abstract:
http://www.envplan.com/cgi-bin/pion/epdisp.pl?query=/ep/epa/abstracts/a29/a290789.htmlWallace

Wallace D, Wallace R. A plague on your houses: how New York was burned down and national public health crumbled. New York: Verso; 1998.
 

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