The Lowdown on SYNDEMIC

... plus an interview with prevention guru Ron Stall.

This is very interesting stuff, please give it a read!

All the following comes to you as an excerpt via NASTAD's
July 2007 HIV Prevention Bulletin.

NASTAD is the National Alliance of State and Territorial AIDS Directors.

To read the bulletin in its entirety, click here.

The Lowdown on Syndemic

What is a Syndemic?

Attempting to explain the links between substance abuse, violence and AIDS in populations of urban women in the U.S., anthropologist Merrill Singer first published the term "syndemics" in 1992. Syndemics is defined as "two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population."

Model of a Syndemic


A syndemic orientation emphasizes examination of the ties, or connections, between health concerns. Rather than focusing on a specific disease, a syndemic orientation looks first at a particular community to understand the causes of disease burden and to identify what is needed to promote the community's overall health. According to the CDC, 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?

CDC goes on to note that, "...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 this explicit acknowledgement, a syndemic orientation maintains, first and foremost, that diseases and other health conditions are tied together within certain populations. This idea offers another frame within which programs can begin to address the collective needs of a population. If successful, programs can hope to begin to alter the cycle of disease and disparity within marginalized population groups.


Why is Syndemic Orientation Important to Prevention?

For several reasons, a syndemic orientation lends itself well to prevention of HIV, viral hepatitis and STD. First, HIV, viral hepatitis, and STD are often transmitted in the same ways: unprotected sexual activity with an infected person; sharing of unclean needles, syringes and other paraphernalia with an infected person; and during birth. Accordingly, the strategies to prevent or control these diseases are often the same. Second, these diseases most often impact the same high-risk communities. Third, the presence of one of these diseases has the potential to facilitate the transmission or acquisition of a second or third disease. Fourth, the diseases share many of the same direct and indirect contributing factors, like gender inequality and poverty. Fifth, other "afflictions" that impact communities where HIV, viral hepatitis and STD disease burden is high are, for the most part, the same: substance use, mental health concerns, incarceration, violence, etc. And, finally, the institutions that take leadership over addressing the concerns associated with these diseases are becoming more and more integrated in their structures and philosophies.

On its website, CDC states:

The medical model of disease specialization, once praised for its utility and versatility, is proving inadequate for confronting such contemporary public health challenges as eliminating health disparities. Although conventional prevention programs have had strong effects, for the most part the categorical approach has failed to assure the conditions for overall community health, and it has done little to spread successes equitably among subgroups in society.6

Given the HIV, viral hepatitis, and STD disease burden in certain populations in the U.S., specifically African-Americans, white and Latino men who have sex with men (MSM) and injection drug users, programs must strive to identify comprehensive solutions to address the multiple concerns of these marginalized populations.

An Interview with Ronald Stall

To better understand how a syndemic orientation can help inform public health programs' desires to address the broader concerns of a community's health and wellness, NASTAD interviewed Ronald Stall, Professor and Assistant Dean at the University of Pittsburgh's Graduate School of Public Health.

NASTAD: Describe syndemic orientation.

Stall: It would be useful to start with a definition of what a syndemic is. To use the medical definition, it refers to a cluster of epidemics that act additively to predict other epidemics. Other phrases that have been used to convey the same idea include "intersecting epidemics" and "twin epidemics," among other phrases. In HIV research, we often see interconnections between HIV and substance use, HIV and violence, HIV and depression, HIV and childhood sexual abuse, among other problems. These intersection epidemics can all be described as "syndemics."

NASTAD: Describe what your research has shown about syndemics.

Stall: One of the striking findings regarding MSM in the context of AIDS has been the high prevalence rates of other dangerous health conditions found even in population-based samples of gay men when compared to other samples of men. That is, rates of depression, drug use, violence victimization, childhood sexual abuse, tobacco use and other health problems are generally higher among MSM than among other populations of men. We were struck by this consistent finding and decided to take a closer look at the interconnections of these epidemics among gay male populations. More specifically, we took a look at the interconnections between substance use, partner violence, childhood sexual abuse and depression and found that that these four epidemics function to reinforce each other among gay male populations, and together also function to raise both levels of current sexual risk-taking as well as HIV infection itself. The interconnections between substance use, childhood sexual abuse, depression and partner violence operate as a complex syndemic that drives HIV risk among gay men.

NASTAD: How do the findings supports consideration of syndemics in increasing community health and reducing disease burden and health disparities?

Stall: The phenomenon raises an interesting question: If there are four high prevalence psychosocial epidemics that work to raise levels of risk for HIV infection among gay men, why does HIV prevention work focus primarily on sexual risk-taking among gay men and generally ignore co-occurring psychosocial problems? Put another way, we now have a set of meta-analyses to show that model HIV prevention programs work to lower risk by about a third. Could we increase the effect of HIV prevention work even further if our interventions took into account the co-existing conditions that may keep men from responding more fully to prevention messages? Putting the question in the broadest frame, could we increase the effectiveness of HIV prevention work among gay men by partnering with violence prevention, substance abuse treatment and mental health efforts within gay communities?

NASTAD: How can syndemic orientation be operationalized within categorical public health programs?

Stall: We need to identify ways via funding streams to increase cross-agency collaborations and to encourage "cross-epidemic" thinking when providing services. As one example, if a young gay man seeks shelter from a violence prevention agency because his partner is beating him, providers should automatically screen for substance abuse, HIV and depression while also trying to find him safe housing.

Looking ahead, I'd like to see some, or a cluster, of funding agencies attempt a demonstration project where funding streams could be mingled to deal with syndemic situations, with careful process and uncontrolled outcome data to measure the effects of this new way of providing front line public health services.