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Syndemics Overview - What Principles Characterize a Syndemic Orientation?

A syndemic orientation is primarily distinguished from other perspectives by its explicit emphasis on examining connections between health-related problems. With this concern, it offers a broader framework for understanding how multiple health problems interact in particular settings. A syndemic orientation elevates public health inquiry beyond its many individual categories to examine directly the conditions that create and sustain overall population health.

The idea of preventing syndemics builds upon proven principles of epidemiology, which have been applied largely to the first tier of a highly complex world. The transforming effect of increasing scale is captured by the Sufi saying

"You think that if you understand one, you understand two-because one and one are two. But you must also understand 'and'."

Similarly, the notion of a syndemic shows that at a population level there is more to public health work than the study of isolated health problems. It reminds us that we do not yet know precisely what happens when two (or more) epidemics interact, nor how powerful interventions can be if they are planned to disrupt those forces that hold multiple diseases together.

Acknowledging the distinction between a single epidemic and the phenomenon of syndemics expands the science, practice, and policy aspects of public health work. Traditionally, research protocols, prevention programs, policy interventions, and other aspects of public health practice have focused on one disease or risk factor at a time, leaving other health problems to be addressed by parallel enterprises. This categorical (i.e., single issue) approach is often used even though there is a high probability that several of the conditions that threaten a given population's health will have common social, environmental, behavioral, or biological determinants. Under a syndemic orientation, such forces would be addressed in an integrated, networked fashion.

The Encyclopedia of Public Health contains an entry that describes the unique conceptual plane inherent in a syndemic orientation.  Writing about syndemics within the broader realm of anthropology and public health, Kate MacQueen observes that  

"The syndemic model provides an important intermediate model that frames the investigation of community level outcomes in terms of individual behavior, local processes, and higher level processes. The syndemic model raises difficult questions and challenges public health to address the root causes of health disparities. By introducing a multi-level, dynamic epidemiological perspective, it points toward the need to develop and evaluate systems- and community-level interventions that target linked processes." (From: MacQueen KM, in Breslow et.al, 2002)

Whereas the usual public health approach begins by defining the disease in question, a syndemic orientation first defines the people in question.  With this frame of reference, it goes on to identify links among the entire set of issues that create excess burden of disease among the group's members. In practice, a syndemic orientation follows a specific line of questioning:

• Who is sick (with which diseases)? 
• Why those people? 
• Why those diseases? 
• What can be done to create (or restore) the conditions for optimal health? 
• Under what circumstances do interventions contribute to improvements in health status and health equity?

These are provocative questions because diseases in human populations do not occur randomly.  In virtually all societies, the heaviest burden of disease falls upon those who are socially marginalized, disenfranchised, or oppressed.  With few exceptions, even emerging diseases that first strike members of the majority eventually gravitate to take hold among minorities. This dynamic concentrates disease among disadvantaged groups, who then become even more vulnerable as health threats reinforce one another in a vicious cycle.

The clustering of health-related problems can occur for many reasons.  For instance, "separate" health concerns are actually linked if they

• Are caused by the same biological agent (e.g., bubonic, pneumonic, and septicemic plague are different diseases, each with a distinctive clinical manifestation and medical course, yet all three are caused by one organism, Yersinia pestis)
  
• Share risk or protective behaviors (e.g., cancer, heart disease, emphysema, and dozens of other diseases are all linked to tobacco use)
  
• Respond to similar environmental conditions (e.g., obesity, diabetes, and asthma are all affected in part by a community's transportation infrastructure)
  
• Have reciprocal or interdependent effects (e.g., alcoholism and depression can reinforce each other, exacerbating both conditions)
  
• Are managed by the same or similar organizations (e.g., strategies for addressing intentional injury place a greater emphasis on primary prevention when they are planned and evaluated by public health organizations, as compared to approaches taken by law enforcement, criminal justice, or even mental health agencies.  These distinctions underscore the fact that all programs under an organization's sphere of responsibility tend to be commonly affected by that organization's context, including its core philosophy, mission, leadership, management, resources, partners, history, and other collective attributes).

[Note: This is a preliminary list of potential epidemic ties.  Research is underway to explore and define a complete typology of the ways that health-related problems could be linked.]

When several health problems concentrate by person, place, or time, the real forces that connect them are often unrecognized or minimized due to the categorical nature of most epidemiological analyses (notable exceptions can be found in social epidemiology; see Krieger N, 2001a, 2001b). The problem, however, is not inherent in the science of epidemiology. On the contrary, epidemiologists are trained to see diseases emerging from interactions of an agent, host, and environment (e.g., CDC 2001). This same typology (or one similar) could perhaps be used on a higher level of analysis to investigate connections between different diseases, but such questions are not commonly asked.

A syndemic orientation, by definition, prompts extensive inquiry into the conditions that create and sustain health, questioning how and why those conditions might differ among groups. For these reasons a syndemic orientation provides a more precise scientific framework for understanding and preventing the conditions that perpetuate health inequities.

Next: When Is It Appropriate or Inappropriate to Use a Syndemic Orientation? >>

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References

CDC.  Introduction to Epidemiology.  Centers for Disease Control and Prevention: Atlanta, GA. 2001.  Accessed on October 2, 2001.
HTML

Krieger N. A glossary for social epidemiology.  Journal of Epidemiology and Community Health 2001;55:693-700.
HTML (http://jech.bmjjournals.com/cgi/content/full/55/10/693) or PDF (http://jech.bmjjournals.com/cgi/reprint/55/10/693.pdf)

Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. International Journal of Epidemiology 2001;30:668-77.
HTML (http://ije.oupjournals.org/cgi/content/full/30/4/668) or PDF (http://ije.oupjournals.org/cgi/reprint/30/4/668.pdf)

MacQueen KM.  Anthropology and public health.  In Breslow L, Green LW, Keck W, Last J, McGinnis M. (Eds.). Encyclopedia of Public Health. New York: Macmillan, 2002.

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