Unmasking Syndemics: A Call for Holistic Healthcare Approaches
Coined by medical anthropologist Merrill Singer in the late 20th century, syndemics describe "synergistically related" epidemics that cluster together and arise from harmful social conditions. According to Singer, a syndemic occurs when a) two or more diseases or health conditions cluster together, b) these conditions worsen each other and increase the overall health burden, and c) social conditions, such as social isolation and poverty, create conditions for clustering and synergistic interaction (Laine, 2022).
To explain simply, imagine someone has a cold. It's bothering, but they'll likely recover on their own. Now, imagine this person is also stressed from work, has trouble affording healthy food, and doesn't have access to reliable healthcare. Suddenly, that simple cold might become more serious and take longer to get over. That's the basic idea of a syndemic. It's when two or more health problems (like the cold and stress) interact with each other and worsen each other's effects, making them harder to deal with. But it's not just about the health problems themselves. Syndemics are also caused by things like poverty, lack of education, and unhealthy environments. These social factors create conditions where the health problems can "team up" and become more dangerous.
The term ‘Syndemics’ has emerged as a powerful concept in public health, challenging traditional disease models and demanding a more holistic approach to healthcare. NITI Aayog's Vision 2035 - Public Health Surveillance in India, highlights the threats posed by syndemics to population health outcomes and emphasizes the need to address them.
Singer introduced the concept of syndemics with the acronym SAVA (Substance Abuse, Violence, AIDS). Today we can see it clearly illustrated in Northeast India. According to NACO, high HIV prevalence (A) in states like Manipur, Mizoram, and Nagaland coexists with injectable drug use (SA) and human trafficking (V). This demonstrates how multiple health issues and social factors can cluster together and worsen each other's effects.
With time, our understanding of syndemics evolved and newer terms like VIDDA (Violence, Immigration, associated isolation, Depression, and Abuse) emerged exemplified today in the multifaceted nature of crises like the Syrian conflict and the Rohingya crisis in Bangladesh which often involve a complex interplay between violence (V), displacement(I), social isolation, mental health issues(D) and trafficking(A).
Further, nothing stands out more as a stark illustration of a global syndemic than the recent COVID-19 outbreak. It saw a clustering of health issues (COVID-19 complications, existing comorbidities and also a mental health epidemic fuelled by shift to remote work), their worsening by social factors (disproportionate impact on the informal sector, women and migrants) and disparate global outcomes (vaccine nationalism).
India and the world are rife with such examples. The US saw the opioid epidemic intertwined with hepatitis C, in India HIV/AIDS and TB form a synergistic cycle and co-exist amongst poverty. Further, rapid urbanization, characterized by the World Bank as "slow, messy, and partly hidden," contributes to high urban air pollution, fuelling a respiratory disease syndemic. All these linkages underscore how health issues are being viewed not in isolation but rather as intertwined with complex socio-economic factors.
However, despite its growing recognition, the theory of syndemics faces critiques. Firstly, some argue, that the theory, while focusing on syndemic-level factors, may neglect individual variations in biology, behaviour, and social context. For example, attributing an entire community's obesity solely to poverty neglects individual factors like genetics or personal choices, potentially leading to a reductionist perspective. Secondly, they question the empirical evidence supporting syndemic interactions, arguing that proving the "synergistic interaction" of health conditions is challenging due to the complex nature of causal relationships and the influence of numerous confounding factors. Consequently, the empirical foundation of syndemics is considered less robust compared to traditional, disease-specific models. Thirdly, they argue that concerns exist regarding the practical implementation of the syndemic theory, including the feasibility of collaboration among various stakeholders and potential conflicts in governance demands.
Supporters however, champion the syndemic theory as an enhancer of understanding rather than a diminisher of it. According to them, Syndemic Theory does acknowledge individual variations, but while doing so it delves deeper by emphasizing the interconnectedness of social determinants and health outcomes. Example: In maternal health and child stunting the traditional approach might solely focus on factors like maternal nutrition or prenatal care. However, the syndemic lens examines the bigger picture, recognizing how poverty, limited education, and sanitation access can exacerbate nutritional deficiencies and healthcare gaps, ultimately contributing to stunting. Studies in India and Bangladesh illustrate this link, showcasing the clear impact of socio-economic factors on child health. This way, a broader understanding allows for interventions that address not just individual needs but also the systemic issues that perpetuate health disparities, leading to more equitable and sustainable improvements in maternal and child well-being.
Further, advocates assert that though proving syndemic interactions is challenging, the intricate nature of health issues today demands a move towards dynamic causation understanding. While traditional models may struggle with such intricacies, syndemic theory excels in it. Example: Diabetes and mental health are traditionally viewed as separate issues, but a syndemic lens may reveals their intricate connection. Chronic stress and depression can worsen diabetes management, while conversely, diabetes complications can trigger anxiety and fear, impacting self-care. Studies in Canada and India confirm this bidirectional link, showcasing how social factors like poverty further exacerbate both conditions. Furthermore, supporters argue that while practical implementation poses challenges, syndemic theory prompts a beneficial shift toward what is now called an ‘adaptive and collaborative governance’. Example: The response to the COVID-19 pandemic showcased the need for adaptive governance. Countries that implemented adaptive strategies, such as flexible lockdowns and community engagement, demonstrated better pandemic outcomes. Syndemic theory encourages such adaptability, allowing for a more resilient response to health crises.
As we seek medical breakthroughs, it's crucial to extend our gaze beyond laboratories, addressing root causes fuelling the syndemic fire. The ongoing dialogue between critics and supporters refines the theory, recognising health challenges' complexity while remaining practically applicable. Acceptance that healthcare needs a paradigm shift involves breaking down silos and fostering collaboration. According to a newer understanding, health is more than disease absence; it's a complex interplay of biological, social, economic, and environmental factors. Recognising this is crucial for effective healthcare addressing syndemics. Further, Syndemic awareness demands a re-evaluation of public health policies. Policymakers must move beyond short-term, disease-specific interventions and invest in long-term strategies addressing interconnected health challenges and social determinants. By tackling poverty, education, and healthcare access, we can begin dismantling conditions perpetuating syndemics. India recognising this has been moving towards this ‘One Health Approach’ with schemes such as the Ayushman Bharat, POSHAN Abhiyaan and Swachh Bharat Abhiyaan.
Recently, news was abuzz with a new term ‘Polycrisis’ which was introduced by World Economic Forum (WEF) in its Global Risks Report 2023 to describe the convergence of crises in economics, politics, geopolitics, and the environment, all reinforcing one another and creating increasingly challenging circumstances. This echoes and bolsters the idea of syndemics, emphasizing the need for a comprehensive approach to address intertwined issues. It underscores the imperative of adopting a ‘Systems Approach’, recognizing the interdependencies between various domains and advocating for holistic solutions. Just as Polycrisis necessitates transcending disciplinary boundaries and embracing collaborative strategies, syndemic theory calls for a shift away from disease-specific interventions towards a more integrated healthcare approach. By acknowledging the interconnectedness and advocating for systemic solutions, we can aspire to 'build back better' and pave the way for a healthier, more resilient future.
References
Hoke, M. K., & McCabe, K. A. (2022, November 7). Malnutrition, illness, poverty, and infant growth: A test of a syndemic hypothesis in Nuñoa, Peru. Science Direct. Retrieved January 4, 2024, from https://www.sciencedirect.com/science/article/abs/pii/S0277953621000526
Laine, E. (2022, May 25). What are syndemics, and why do they matter in health governance? Demos Helsinki. Retrieved January 4, 2024, from https://demoshelsinki.fi/2022/05/25/what-are-syndemics/
