Intersectionality and syndemics: A commentary.

This commentary addresses the possibilities and pitfalls of putting intersectionality and syndemics into conversation with each other. We engage with two studies published in this issue: the first on the health-related vulnerabilities among LGBTQ + Latinx men in Orlando after the Pulse nightclub shooting, and the other on syndemic health issues brought about by social and structural inequities among young Black gay, bisexual, and other men who have sex with men (GBM). Both manuscripts suggest that intersectionality and sydemics can be integrated or possibly merged to build effective health equity focused interventions for marginalized populations. We, however, argue that there are several methodological, ontological, and epistemological challenges in bringing together intersectionality and syndemics. Our argument coalesces around three key points. First, we contend that while it is feasible to think of their integration as useful to the study of health disparities, syndemics offers no added benefit to health scholarship grounded in intersectional analysis. Second, we argue that assumptions of common ground between intersectionality and syndemics rest on equating theories of interaction and additivity with critiques of mutual configurations of ideology, power structures, and social categories. Finally, we maintain that if intersectionality and syndemics are to be in conversation with each other, it must be done with the recognition and examination of where each framework situates itself relative to methodology, praxis, and power. Using our own work and those of intersectional feminist scholars, we demonstrate how the stakes of intersectionality diverge radically from those of syndemics, and how syndemics has the potential to undermine the significance of intersectionality for addressing issues of health equity.

Exceptionalism at the End of AIDS.

HIV/AIDS exceptionalism promoted compassion, garnered funding, built institutions, and shaped regulatory and research agendas under emergency conditions. Globally, however, HIV/AIDS exceptionalism has further fragmented fragile health service delivery systems in vulnerable, marginalized communities and created perverse incentives to influence seropositive individuals' behaviors. Even where HIV epidemics are viewed as "controlled" or "resolved" (as in the United States), ending AIDS requires eliminating exceptionalism, normalizing justice-based approaches to HIV care, and explicitly acknowledging how power dynamics shape popular narratives and practices.

Reparations for Black American Descendants of Persons Enslaved in the U.S. and Their Estimated Impact on SARS-CoV-2 Transmission.

Background In the United States, Black Americans are suffering from significantly disproportionate incidence and mortality rates of COVID-19. The potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored. Methods We compared the COVID-19 time-varying R t curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates ß i→j for 4 cells of the simplified next-generation matrix (from which R 0 is calculated for structured models) for the outbreak in Louisiana. Lastly, we modeled the effect that monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention ß i→j . Results Once their respective epidemics begin to propagate, Louisiana displays R t values with an absolute difference of 1.3 to 2.5 compared to South Korea. It also takes Louisiana more than twice as long to bring R t below 1. We estimate that increased equity in transmission consistent with the benefits of a successful reparations program (reflected in the ratio ß b→b / ß w→w ) could reduce R 0 by 31 to 68%. Discussion While there are compelling moral and historical arguments for racial injustice interventions such as reparations, our study describes potential health benefits in the form of reduced SARS-CoV-2 transmission risk. As we demonstrate, a restitutive program targeted towards Black individuals would not only decrease COVID-19 risk for recipients of the wealth redistribution; the mitigating effects would be distributed across racial groups, benefitting the population at large.

Indirect rule redux: the political economy of diamond mining and its relation to the Ebola outbreak in Kono District, Sierra Leone.

This article explores the relationship between the 2014-2016 Ebola outbreak and the political economy of diamond mining in Kono District, Sierra Leone. The authors argue that foreign companies have recycled colonial strategies of indirect rule to facilitate the illicit flow of resources out of Sierra Leone. Drawing on field research conducted during the outbreak and in its aftermath, they show how this 'indirect rule redux' undermines democratic governance and the development of revenue-generation institutions. Finally, they consider the linkages between indirect rule and the Ebola outbreak, vis-à-vis the consequences of the region's intentionally underdeveloped health care infrastructure and the scaffolding of outbreak containment onto the paramount chieftaincy system.

Cet article explore la relation entre l'épidémie d'Ebola de 2014­2016 et la politique économique de l'extraction de diamants dans le district de Kono, au Sierra Leone. Les auteurs avancent que des entreprises étrangères ont recyclé les stratégies coloniales de la « règle indirecte ¼ afin de faciliter le flux de ressources hors du Sierra Leone. S'appuyant sur de la recherche de terrain conduite pendant l'épidémie et après, il est démontré comment ce retour de la « règle indirecte ¼ sape la gouvernance démocratique et le développement d'institutions qui génèrent du revenu. Enfin, cet article s'intéresse aux liens entre la « règle indirecte ¼ et l'épidémie d'Ebola, vis-à-vis des conséquences de l'infrastructure de soins de santé intentionnellement sous-développée dans la région et les tentatives de confinement de l'épidémie pour le système essentiel de chefferie.

Temporality and Positive Living in the Age of HIV/AIDS--A Multi-Sited Ethnography.

Drawing on comparative ethnographic fieldwork conducted in urban Mozambique, United States, and Sierra Leone, the article is broadly concerned with the globalization of temporal logics and how specific ideologies of time and temporality accompany health interventions like those for HIV/AIDS. More specifically, we explore how HIV-positive individuals have been increasingly encouraged to pursue healthier and more fulfilling lives through a set of moral, physical, and social practices called "positive living" since the advent of antiretroviral therapies. We describe how positive living, a feature of HIV/AIDS programs throughout the world, has taken root across varied political, social and economic contexts and how temporal rationalities, which have largely been under-examined in the HIV/AIDS literature, shape communities' responses and interpretations of positive living. Our approach is ethnographic and comparative, with implications for how anthropologists might think about collaboration and its analytical possibilities.

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal.

BACKGROUND: Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. METHODS: We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. RESULTS: We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. CONCLUSION: The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Enumeration, identity, and health.

Although the production of national spaces, citizens, and populations through enumerative practices has been well explored in a variety of disciplines, anthropological methods and analysis can help to illuminate the everyday practices of enumeration, their unexpected consequences, and the co-construction of identities through these processes by both the "counted" and the "counters." The authors in this special issue illustrate how enumeration inflects lived experiences, produces subjectivities, and reconfigures governance. Focusing on the spatial, temporal, ideological, and affective dimensions of the techniques of enumeration, the authors also provide insights into the multiple forms of biopolitical expertise and knowledge that accumulate legitimacy through numerical discourse. They also highlight the ways in which governing structures, institutional and cultural norms, market logics, and rational-technical interventions influence the relationship among numerical categories, subjectivity, and everyday experience.

Exceptional suffering? Enumeration and vernacular accounting in the HIV-positive experience.

Drawing on 17 months of ethnographic fieldwork in Freetown, Sierra Leone, I highlight the recursive relationship between Sierra Leone as an exemplary setting and HIV as an exceptional disease. Through this relationship, I examine how HIV-positive individuals rely on both enumerative knowledge (seroprevalence rates) and vernacular accounting (NGO narratives of vulnerability) to communicate the uniqueness of their experience as HIV sufferers and to demarcate the boundaries of their status. Various observers' enumerative and vernacular accounts of Sierra Leone's decade-long civil conflict, coupled with global health accounts of HIV as exceptional, reveal the calculus of power through which global health projects operate. The contradictions between the exemplary and the exceptional-and the accompanying tension between quantitative and qualitative facts-are mutually constituted in performances and claims made by HIV-positive individuals themselves.