Syndemics and the biosocial conception of health.

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

The Effects of Water Insecurity and Emotional Distress on Civic Action for Improved Water Infrastructure in Rural South Africa.

The South African constitution ratifies water as a human right. Yet millions of citizens remain disconnected from the national water infrastructure. Drawing on data collected in 2013-2014 from women in northern South Africa, this study explores "water citizenship"-individual civic engagement related to improving water service provision. Literature indicates that water insecurity is associated with emotional distress and that water-related emotional distress influences citizen engagement. I extend these lines of research by assessing the connection that water insecurity and emotional distress may collectively have with civic engagement to improve access to water infrastructure.

Assessing the environmental context of hand washing among school children in Limpopo, South Africa.

Despite its simplicity and efficacy, the promotion of hand washing for disease prevention remains a challenge particularly in resource-limited settings. Here we report on a quasi-experimental school-based study that aimed to improve habitual hand washing. Significant increases in hand washing occurred following improvements in hygiene and sanitation facilities (School A: t=13.86, p=0.0052). Smaller increases in hand washing occurred following education (School A: t=2.63; p=0.012; School B, no infrastructure improvements: t=1.66, p=0.239). Health policy and programming need to pay greater attention to the interplay of the structural, social, and individual dimensions of unique contextual environments that influence habitual behaviours.

Ectoparasitic Syndemics: Polymicrobial Tick-borne Disease Interactions in a Changing Anthropogenic Landscape.

Based on an assessment of the available research, this article uses syndemic theory to suggest the role of adverse bio-social interactions in increasing the total disease burden of tick-borne infections in local populations. Given the worldwide distribution of ticks, capacity for coinfection, the anthropogenic role in environmental changes that facilitate tick dissemination and contact, evidence of syndemic interaction in tick-borne diseases, and growing impact of ticks on global health, tick-borne syndemics reveal fundamental ways in which human beings are not simply agents of environmental change but objects of that change as well.

Social models of HIV risk among young adults in Lesotho.

Extensive research over the past 30 years has revealed that individual and social determinants impact HIV risk. Even so, prevention efforts focus primarily on individual behaviour change, with little recognition of the dynamic interplay of individual and social environment factors that further exacerbate risk engagement. Drawing on long-term research with young adults in Lesotho, I examine how social environment factors contribute to HIV risk. During preliminary ethnographic analysis, I developed novel scales to measure social control, adoption of modernity, and HIV knowledge. In survey research, I examined the effects of individual characteristics (i.e., socioeconomic status, HIV knowledge, adoption of modernity) and social environment (i.e., social control) on HIV risk behaviours. In addition, I measured the impact of altered environments by taking advantage of an existing situation whereby young adults attending a national college are assigned to either a main campus in a metropolitan setting or a satellite campus in a remote setting, irrespective of the environment in which they were socialised as youth. This arbitrary assignment process generates four distinct groups of young adults with altered or constant environments. Regression models show that lower levels of perceived social control and greater adoption of modernity are associated with HIV risk, controlling for other factors. The impact of social control and modernity varies with environment dynamics.

Conceptualizing COVID-19 syndemics: A scoping review.

Background: COVID-19's heavy toll on human health, and its concentration within specific at-risk groups including the socially vulnerable and individuals with comorbidities, has made it the focus of much syndemic discourse. Syndemic theory recognizes that social factors create the conditions that support the clustering of diseases and that these diseases interact in a manner that worsens health outcomes. Syndemics theory has helped to facilitate systems-level approaches to disease as a biosocial phenomenon and guide prevention and treatment efforts. Despite its recognized value, reviews of syndemics literature have noted frequent misuse of the concept limiting its potential in guiding appropriate interventions. Objective: To review how the term 'syndemic' is defined and applied within peer-reviewed literature in relation to COVID-19. Design: A scoping review of definitions within COVID-19 literature published between January 1, 2020 to May 15, 2023 was conducted. Searches took place across six databases: Academic Search Premier, CINAHL, JSTOR, MEDLINE/Pubmed, PsycINFO and Scopus. PRISMA-ScR guidelines were followed. Results: Content analysis revealed that COVID-19 has varied clustered configurations of communicable-non-communicable diseases and novel communicable disease interactions. Spatial analysis was presented as a new strategy to evidence syndemic arrangements. However, syndemics continue to be regarded as universal, with continued misunderstanding and misapplication of the concept. Conclusion: This review found that current applications of syndemics remain problematic. Recommendations are made on the design of syndemic studies. A syndemic framework offers an opportunity for systems-level thinking that considers the full complexity of human-disease interactions and is useful to inform future pandemic preparations and responses.

From modeling to morals: imagining the future of HIV PREP in Lesotho.

Amidst growing global endorsements of new biomedical HIV prevention strategies, ARV-based pre-exposure prophylaxis (ARV PrEP) has garnered considerable attention as a potentially promising prevention strategy. Though it may offer more effective protection for certain at-risk groups than conventional prevention strategies (such as sexual partner reduction, condom use, and prevention of mother-to-child transmission), PrEP is more costly. PrEP requires more ongoing contact between individuals and providers, and a level of surveillance from the health system that is not necessary with other preventive measures. In this sense, it represents a new bio-technology for HIV prevention that poses particular challenges for worldwide implementation, given developing countries' struggling health systems and incomplete HIV treatment programs. Since the emergence of PrEP has stimulated ethical discussions premised on incomplete knowledge of efficacy and implementation, this paper explores the ethical parameters of a likely scenario for PrEP usage in a single, resource-poor country. We first develop a plausible model for PrEP deployment and utilization based on current PrEP research, while carefully considering the reigning institutional values of feasibility and effectiveness in global health approaches. Drawing on ethnographic research of HIV treatment and prevention approaches in Lesotho, we address ethical questions arising from this scenario of PrEP delivery. Lesotho presents a compelling and emblematic case study of PrEP's potential successes and pitfalls in a developing country, given the country's high HIV prevalence, struggles to achieve universal access to HIV treatment regimes, continued existence of stigma around the epidemic, and difficulties in addressing persistent social inequalities that fuel infections.

"Solidarity:" A failed call to action during the COVID-19 pandemic.

Global health leaders evoked the concept of "solidarity" to unite citizens in efforts to contain the COVID-19 pandemic. Historically the term has been used in different domains (politics and labor) and in connection to different crises (refugees, immigration, and climate change). Was "solidarity" a useful rallying cry? To assess the impact of health communication efforts to motivate citizen action, surveys were administered at three key moments in the first two years of the pandemic: June 2020 as cases declined globally (n = 90); October 2020 during the second wave of infections in Europe and the US (n = 96); and March 2021 when vaccines became available to adults (n = 100). Calls for solidarity motivate fleeting efforts, irrespective of perceived risk, and are less likely to inspire action for the public good as compared to other motivators such as team reasoning and compassion. While the pandemic revealed the capacity of citizens to support one another in the absence of state intervention, calls for solidarity are ineffective in inspiring long-term engagements toward a common good.

A new approach to measuring the synergy in a syndemic: Revisiting the SAVA syndemic among urban MSM in the United States.

ABSTRACTSyndemic theory hypothesises that observed clusters of diseases are the result of harmful social conditions. Critiques of syndemics present the theory as ambiguous and lacking empirical evidence. Syndemics are evidenced through qualitative assessments drawing on observations, epidemiology, and biomedical evidence to explain bio-bio and bio-social interactions. Quantitative syndemic studies commonly apply a summative approach, whereby the outcome is a result of the cumulative effect of the individual elements. More recently, quantitative studies apply analyses to assess mechanical interactions among conditions. This paper applies a synergy factor analysis to measure synergy - the enhancement of the effect of one element on the effect of the others. Data from the canonical quantitative syndemic analysis study was reanalysed to assess synergy among the elements of the SAVA syndemic (substance ab/use, violence, HIV/AIDS). Contrary to original study findings, which applied a summative approach, no synergy was measured. Synergistic interactions were confirmed among a subset of the study population; the effects of substance ab/use and violence on HIV were more than two times greater in White MSM than the predicted joint effect (SF = 2·32, 95%CI 1·02-5·11, p = 0·044), indicating synergy. Synergy factor analysis presents an accessible tool to measure syndemic interactions and facilitate timely global health responses.

Are There Global Syndemics?

In this article, we address the nature of syndemics and whether, as some have asserted, these epidemiological phenomena are global configurations. Our argument that syndemics are not global rests on recognition that they are composed of social/environment contexts, disease clusters, demographics, and biologies that vary across locations. These points are illustrated with the cases of syndemics involving COVID-19, diabetes mellitus, and HIV/AIDS. We draw on theoretical discourse from epidemiology, biology, and anthropology to present what we believe is a more accurate framework for thinking about syndemics with shared elements.

Syringe-mediated syndemics.

One consequence of the global HIV/AIDS pandemic has been the emergence of a broad awareness of the potential role of syringes in the transmission of infectious diseases. In addition to HIV/AIDS, the use of unsterile syringes by multiple persons has been linked to the spread of Hepatitis B, Hepatitis C, Leishmaniasis, malaria and various other infections. The purpose of this paper is to extend awareness of the grave risks of multiperson syringe use by examining the role of this behavior in the development of infectious disease syndemics. The term syndemics refers to the clustering, often due to noxious social conditions, of two or more diseases in a population resulting in adverse disease synergies that impact human life and well-being. The contemporary appearance and spread of identified syringe-mediated syndemics, and the potential for the emergence of future syringe-mediated syndemics, both of which are reviewed in this paper, underline the importance of public health measures designed to limit syringe-related disease transmission.

In the shadow of HIV & TB: A commentary on the COVID epidemic in South Africa.

While COVID-19 has become a global pandemic that has spread to all regions of the globe, local historic, health, and socio-environmental factors shape the epidemiological contours, response, and social challenges present within each affected nation. Thus, while countries like China, Italy, Iran, Brazil, and the United States have all been hard hit by the pandemic, there are critical differences across these nations in a number of variables (e.g. demographic features, health histories, healthcare systems, infection case rates, case fatality rates, national responses). In other words, within the global pandemic there are multiple importantly distinct national epidemics. Overcoming the grave threats to public health presented by COVID-19 requires both international cooperation and country-specific efforts that reflect local histories, needs, and resources. Already concerns are being expressed among health officials about how COVID-19 might be devastating in Africa. Currently, South Africa has the highest number of diagnosed COVID-19 cases on the continent and has been identified as being at high risk in the pandemic. This paper examines the public health response to the COVID-19 threat, how the prior and ongoing HIV and TB epidemics shape the COVID-19 epidemic and influence the response, and the potential ramifications of the response.

Whither syndemics?: Trends in syndemics research, a review 2015-2019.

As originally conceived, syndemics refers to complex epidemics involving two types of adverse interaction - the clustering and interactions of two or more diseases or health conditions (the biological-biological interface) and social environmental factors (the biological-social interface). The theory has been widely applied in the fields of medicine, public health and anthropology, but how the concept is conceptualised and investigated in new syndemics literature remains unclear. This paper offers a scoping review of recent syndemics literature aiming to address the question: Where have scholars taken the syndemics concept? Five bibliographic databases were searched for titles containing 'syndemic[s]' revealing 334 records. A total of 143 journal articles, 23 book chapters, 21 commentaries, 2 books and 5 dissertations were assessed. Citations were classified into five categories: syndemics (n = 22), potential syndemics (n = 34), socially determined heightened burden of disease (n = 29), harmful disease cluster (n = 32) and additive adverse conditions (n = 71). The limited number of citations meeting the definition of a syndemic arrangement highlights the challenges related to describing and empirically supporting the biological-biological and biological-social relationships. Nevertheless, there is value in retaining the original, holistic, biosocial meaning of syndemics to identify and detail the casual pathways and mechanisms of interactions.

Public health's social contract: An obstacle in the advancement of effective HIV technologies.

Evidence from the past 40 years of HIV technology development and implementation indicates that the public health social contract - with its expectations of patient/citizen compliance - has hampered global disease control efforts. Despite the availability of a wide array of effective technologies, including antiretroviral drugs as treatment and prevention, voluntary medical male circumcision procedures, and newly developed intravaginal ring products, new infections among adults globally have not decreased significantly. In this paper, I describe a historical trend of limiting access to effective biomedical technologies to those deemed most deserving and compliant given concerns of misuse (non-adherence), product repurposing (not using the product for purposes originally intended), and the incitement of autonomy (increasing the risk of public exposure to diseases given personal protection from a specific disease). Examining the expectations of good citizenship (compliance, adherence, appropriate product use, and continued risk reduction) as it relates to human-technology interactions, reveals a continuing narrative of initially restricting access to newer technologies perceived fragile or costly based on an assessment of patient/citizen worth. In this, the conventional public health social contract continues to be an obstacle in the advancements of technologies to effectively reduce the global burden of HIV.

Making voluntary medical male circumcision a viable HIV prevention strategy in high prevalence countries by engaging the traditional sector.

Voluntary medical male circumcision (VMMC) has been rapidly accepted by global HIV policy and donor institutions as a highly valuable HIV prevention strategy given its cost-effectiveness, limited interactions with a health facility, and projected long-lasting benefits. Many southern African countries have incorporated VMMC into their national HIV prevention strategies. However, intensive VMMC promotion programs have met with limited success to date and many HIV researchers have voiced concerns. This commentary discusses reasons behind the less-than-desired public demand and suggests how inclusion of the traditional sector - traditional leaders, healers, and circumcisers - with their local knowledge, cultural expertise and social capital, particularly in the realm of social meanings ascribed to male circumcision, may improve the uptake of this HIV prevention strategy. We offer Lesotho and Swaziland as case studies of the integration of universal VMMC policies; these are countries with a shared HIV burden, yet contrasting contemporary socio-cultural practices of male circumcision. The similar hesitant responses expressed by these two countries towards VMMC remind us that the incorporation of any new or revised and revitalized public health strategy must be considered within unique historical, political, economic, and socio-cultural contexts.

Conceptualizing Biopolitics: Citizen-State Interactions in the Securing of Water Services in South Africa.

Despite constitutional obligations to provide clean water to all citizens in South Africa, access to water and related services remains highly contested. The discord between constitutional promises and lived realities of water access, particularly through national infrastructure, provides a platform on which to examine Foucauldian notions of biopolitics, the control of populations through technologies of governing. Drawing on the situations of residents in the rural Vhembe district in the north eastern corner of the country, I examine how individuals conceptualize the relationship that exists between citizen and state and the responsibilities of each in post-Apartheid South Africa as it relates to water access. In addition, I describe strategies employed throughout South Africa to voice rights to water and how these approaches are perceived. Finally, I consider how the three primary forms of 'water citizenship'-citizen, agent, and subject-influence the current and future health of vulnerable residents.

Hesitance towards voluntary medical male circumcision in Lesotho: reconfiguring global health governance.

Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention - voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the country's high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of 'partnerships' has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesotho's domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesotho's resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.

The syndemics of childhood diarrhoea: a biosocial perspective on efforts to combat global inequities in diarrhoea-related morbidity and mortality.

Diarrhoea remains the second leading cause of death in children under 5 years. Moreover, morbidity as a result of diarrhoea is high particularly in marginalised communities. Frequent bouts of diarrhoea have deleterious and irreversible effects on physical and cognitive development. Children are especially vulnerable given their inability to mount an active immune response to pathogen exposure. Biological limitations are exacerbated by the long-term effects of poverty, including reduced nutrition, poor hygiene and deprived home environments. Drawing from available literature, this paper uses syndemic theory to explore the role of adverse biosocial interactions in increasing the total disease burden of enteric infections in low-resources populations and assesses the limitations of recent global calls to action. The syndemic perspective describes situations in which adverse social conditions, including inequality, poverty and other forms of political and economic oppression, play a critical role in facilitating disease-disease interactions. Given the complex micro- and macro-nature of childhood diarrhoea, including interactions between pathogens, disease conditions and social environments, the syndemic perspective offers a way forward. While rarely the focus of health interventions, technologically advanced biomedical strategies are likely to be more effective if coupled with interventions that address the social conditions of disparity.