Other information and sources on syndemics can be found at the following websites:
The Centers for Disease Control and Prevention hosts a website entitle Syndemics Prevention Network. It is found online at: http://www.cdc.gov/syndemics/
Wikipedia, an online encyclopedia has a listing for syndemics at:
http://en.wikipedia.org/wiki/Syndemic
Saturday, May 5, 2007
Health and Social Conditions: The Case of John Hudson
A central tenet of syndemic theory is that diseases do not exist in a social vacuum nor solely within the bodies of those they inflict, and thus their transmission and impact is never merely a biological process. Ultimately, social factors, like poverty, racism, sexism, ostracism, and structural violence may be of far greater importance in the extent of disease spread and the toll taken in human well-being than the nature of pathogens or the bodily systems they infect. As a result of such factors and the resulting interactions among pathogens or other health conditions, the total burden of disease is far greater among those subjected to structural disadvantage compared to populations that are not so encumbered resulting in significant disparities in both social suffering and years of life lost.
These points are illustrated in an important historic epidemiological case. In his speech before the Policy Interpretation Network on Children’s Health held in Amsterdam in 2003, Peter Van den Hazel, an environmental health physician, called attention to this case through his account of the life of John Hudson, a nine year old boy living in London during the 1780s. Illiterate and orphaned, John avoided starvation by working as a chimney sweep. At the time, unskilled child laborers like John had a life expectancy of about 19 years, with a multiplicity of diseases and other health conditions, including malnutrition, exposure to the elements, overwork, and mistreatment, claiming the lives of the children of the urban poor. As a sweep, John’s job was to crawl up into a chimney and scrape the layers of heavy black soot from the inside walls, replace any mortar that became dislodged, and fix cracks in the brickwork. Like other sweeps, his hands and face were badly lacerated from the sharp corners of the brick. Moreover, sweeps regularly would become trapped in the narrower flues or fall to their deaths. In addition, sweeps suffered heavily from a variety of occupational hazards, including asthma, inflammation of the eyes, malformed spines and legs, and tuberculosis, and many suffocated to death. In no small part, such diseases were a byproduct of the most profitable segment of a mastersweep’s business, extinguishing flue fires. To put out such fires, young sweeps like John would be ordered to climb up a chimney until they reached and could put out the fire. Additionally, in 1776 Percival Pott, a London physician, reported on the high incidence of scrotal cancer in young chimney sweeps, one of the first published cases linking socioeconomic status and occupational and environmental health, and, from the perspective syndemics theory, one of the first accounts of an occupational syndemic.
Of note, against all odds, John did not fall victim to the usual causes of death among sweeps. Rather, in October 1783, he was caught breaking into a London home with several friends and stealing some items of clothing and a gun. He only avoided a death sentence because he was charged with breaking and entering rather than burglary. He was sent to the infamous Newgate Prison, then transferred to a prison ship and sent to Australia, along with 50 other children and a number of convicts. He arrived in Australia at age 13. The last official record of John is an Australian government report indicating he received 50 lashes for being outside his prison hut at nine o’clock, a sad but appropriate ending for a story on the social origins of ill health and social suffering.
These points are illustrated in an important historic epidemiological case. In his speech before the Policy Interpretation Network on Children’s Health held in Amsterdam in 2003, Peter Van den Hazel, an environmental health physician, called attention to this case through his account of the life of John Hudson, a nine year old boy living in London during the 1780s. Illiterate and orphaned, John avoided starvation by working as a chimney sweep. At the time, unskilled child laborers like John had a life expectancy of about 19 years, with a multiplicity of diseases and other health conditions, including malnutrition, exposure to the elements, overwork, and mistreatment, claiming the lives of the children of the urban poor. As a sweep, John’s job was to crawl up into a chimney and scrape the layers of heavy black soot from the inside walls, replace any mortar that became dislodged, and fix cracks in the brickwork. Like other sweeps, his hands and face were badly lacerated from the sharp corners of the brick. Moreover, sweeps regularly would become trapped in the narrower flues or fall to their deaths. In addition, sweeps suffered heavily from a variety of occupational hazards, including asthma, inflammation of the eyes, malformed spines and legs, and tuberculosis, and many suffocated to death. In no small part, such diseases were a byproduct of the most profitable segment of a mastersweep’s business, extinguishing flue fires. To put out such fires, young sweeps like John would be ordered to climb up a chimney until they reached and could put out the fire. Additionally, in 1776 Percival Pott, a London physician, reported on the high incidence of scrotal cancer in young chimney sweeps, one of the first published cases linking socioeconomic status and occupational and environmental health, and, from the perspective syndemics theory, one of the first accounts of an occupational syndemic.
Of note, against all odds, John did not fall victim to the usual causes of death among sweeps. Rather, in October 1783, he was caught breaking into a London home with several friends and stealing some items of clothing and a gun. He only avoided a death sentence because he was charged with breaking and entering rather than burglary. He was sent to the infamous Newgate Prison, then transferred to a prison ship and sent to Australia, along with 50 other children and a number of convicts. He arrived in Australia at age 13. The last official record of John is an Australian government report indicating he received 50 lashes for being outside his prison hut at nine o’clock, a sad but appropriate ending for a story on the social origins of ill health and social suffering.
References on Syndemics and Related Issues
References
Altice F., Marinovich, A., Khoshnood, K., Blankenship, K., Springer, S., and Selwyn P. 2005 Correlates of HIV Infection Among Incarcerated Women: Implications for Improving Detection of HIV Infection. Journal of Urban Health (in press)
Chadwick, Douglas 1992/1993 Seeking Meanings. Defenders Magazine. Online at: http://www.defenders.org/bio-bi02.html. Accessed 7/16/05.
Craib, K., Meddings, D., and Strathdee S. 1995 Rectal Gonorrhoea as an Independent Risk Factor for HIV Infection in a Cohort of Homosexual Men. Genitourin Medicine 71:150-4.
Easton, Delia 2004 The Urban Poor: Health Issues. Encyclopedia of Medical Anthropology, Volume 1, pp. 207-213. New York: Kluwer Academic/Plenum Publishers.
Farmer, Paul 1999 Infections and Inequality: The Modern Plagues. Berkeley, CA: University of California Press.
Fowler, R., Lapinsky, S., Hallett, D., Detsky, A., Sibbald, W., and Slutsky, A. 2003 Critically Ill Patients with Severe Acute Respiratory Syndrome. Journal of the American Medical Association 290:367–373.
Freudenberg, Nicholas, Fahs, Marinne, Galea, Sandro, and Greenberg, Andrew 2006 The Impact of New York City’s 1975 Fiscal Crisis on the Tuberculosis, HIV, and Homicide Syndemic. American Journal of Public Health 96(3):424-434.
Ho, David 1996 The Influence of Coinfections on HIV Transmission and Disease Progression. The AIDS Reader 6(4):114-116.
Holmberg, S., Stewart J., and Gerber A. 1988 Prior herpes simplex virus type 2 infection as a risk factor for HIV infection. Journal of the American Medical Association 259:1048-5100.
Hotez, P. 2003 The Hookworm Vaccine Initiative. Washington, D.C.: Sabin Vaccine Institute, Georgetown University.
Johnson, S and Martin, R. 2005 Chlamydophila pneumoniae and Mycoplasma pneumoniae: A Role in Asthma Pathogenesis. American Journal of Respiratory and Critical Care Medicine (in press).
Nusbaum, M., Wallace, R., Slatt, L., and Kondrad, E. 2004 Sexually Transmitted Infections and Increased Risk of Co-infection with Human Immunodeficiency Virus. Journal of the American Osteopathic Association 104(12):527-535.
O'Connor, S., West, S., Lorntz, B., Vinicor, F., and Jorgensen, C. 2004 Women and Infectious Disease—Chronic Disease Interactions [conference summary]. Emerg Infect Dis [serial on the Internet]. Available from http://www.cdc.gov/ncidod/EID/vol10no11/04-0623_14.htm. Accessed May 18, 2005.
Singer, Merrill 1996 A Dose of Drugs, a Touch of Violence, A Case of AIDS: Conceptualizing the SAVA Syndemic. Free Inquiry in Creative Sociology 24(2):99-110.
Singer, Merrill 2006 A Dose of Drugs, A Touch of Violence, A Case of AIDS, Part 2: Further Conceptualizing the SAVA Syndemic. Free Inquiry in Creative 34(1): 39-51.
Singer, Merrill 2006 Something Dangerous: Emergent and Changing Illicit Drug Use and Community Health. Prospect Heights, IL: Waveland Press.
Singer, Merrill 2007 Syndemics. The Encyclopedia of Epidemiology. Thousand Oaks, CA: Sage.
Singer, Merrill, Pamela Erickson, Louise Badiane, Rosemary Diaz, Dugeidy Ortiz, Traci Abraham, and Anna Marie Nicolaysen 2006 Syndemics, Sex and the City: Understanding Sexually Transmitted Disease in Social and Cultural Context. Social Science and Medicine. 63(8):2010-2021.
Singer, M. and Clair, S. 2003 Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context. Medical Anthropology Quarterly 17(4): 423-441.
Soule, J., Olyaei, A., Boslaugh, T., Busch, A., Schwartz, J., Morehouse, S., Ham, J., and Orloff, S. 2005 Hepatitis C Infection Increases the Risk of New-onset Diabetes after Transplantation in Liver Allograft Recipients. American Journal of Surgery 189(5):552-557.
Stall, R., Mills, T., Williamson, J., and Hart, T. 2003 Association of Co-occurring Psychosocial Health Problems and Increased Vulnerability to HIV/AIDS Among Urban men who have Sex with Men. American Journal of Public Health. 93(6).
Visnegarwala, F., Chen, L., Raghavan, S., and Tedaldi, E. 2005 Prevalence of diabetes mellitus and dyslipidemia among antiretroviral naive patients co-infected with hepatitis C virus (HCV) and HIV-1 compared to patients without co-infection. Journal of Infection. 50(4):331-7.
Wasserheit, J. 1992 Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sexually Transmitted Disease 19:61
Altice F., Marinovich, A., Khoshnood, K., Blankenship, K., Springer, S., and Selwyn P. 2005 Correlates of HIV Infection Among Incarcerated Women: Implications for Improving Detection of HIV Infection. Journal of Urban Health (in press)
Chadwick, Douglas 1992/1993 Seeking Meanings. Defenders Magazine. Online at: http://www.defenders.org/bio-bi02.html. Accessed 7/16/05.
Craib, K., Meddings, D., and Strathdee S. 1995 Rectal Gonorrhoea as an Independent Risk Factor for HIV Infection in a Cohort of Homosexual Men. Genitourin Medicine 71:150-4.
Easton, Delia 2004 The Urban Poor: Health Issues. Encyclopedia of Medical Anthropology, Volume 1, pp. 207-213. New York: Kluwer Academic/Plenum Publishers.
Farmer, Paul 1999 Infections and Inequality: The Modern Plagues. Berkeley, CA: University of California Press.
Fowler, R., Lapinsky, S., Hallett, D., Detsky, A., Sibbald, W., and Slutsky, A. 2003 Critically Ill Patients with Severe Acute Respiratory Syndrome. Journal of the American Medical Association 290:367–373.
Freudenberg, Nicholas, Fahs, Marinne, Galea, Sandro, and Greenberg, Andrew 2006 The Impact of New York City’s 1975 Fiscal Crisis on the Tuberculosis, HIV, and Homicide Syndemic. American Journal of Public Health 96(3):424-434.
Ho, David 1996 The Influence of Coinfections on HIV Transmission and Disease Progression. The AIDS Reader 6(4):114-116.
Holmberg, S., Stewart J., and Gerber A. 1988 Prior herpes simplex virus type 2 infection as a risk factor for HIV infection. Journal of the American Medical Association 259:1048-5100.
Hotez, P. 2003 The Hookworm Vaccine Initiative. Washington, D.C.: Sabin Vaccine Institute, Georgetown University.
Johnson, S and Martin, R. 2005 Chlamydophila pneumoniae and Mycoplasma pneumoniae: A Role in Asthma Pathogenesis. American Journal of Respiratory and Critical Care Medicine (in press).
Nusbaum, M., Wallace, R., Slatt, L., and Kondrad, E. 2004 Sexually Transmitted Infections and Increased Risk of Co-infection with Human Immunodeficiency Virus. Journal of the American Osteopathic Association 104(12):527-535.
O'Connor, S., West, S., Lorntz, B., Vinicor, F., and Jorgensen, C. 2004 Women and Infectious Disease—Chronic Disease Interactions [conference summary]. Emerg Infect Dis [serial on the Internet]. Available from http://www.cdc.gov/ncidod/EID/vol10no11/04-0623_14.htm. Accessed May 18, 2005.
Singer, Merrill 1996 A Dose of Drugs, a Touch of Violence, A Case of AIDS: Conceptualizing the SAVA Syndemic. Free Inquiry in Creative Sociology 24(2):99-110.
Singer, Merrill 2006 A Dose of Drugs, A Touch of Violence, A Case of AIDS, Part 2: Further Conceptualizing the SAVA Syndemic. Free Inquiry in Creative 34(1): 39-51.
Singer, Merrill 2006 Something Dangerous: Emergent and Changing Illicit Drug Use and Community Health. Prospect Heights, IL: Waveland Press.
Singer, Merrill 2007 Syndemics. The Encyclopedia of Epidemiology. Thousand Oaks, CA: Sage.
Singer, Merrill, Pamela Erickson, Louise Badiane, Rosemary Diaz, Dugeidy Ortiz, Traci Abraham, and Anna Marie Nicolaysen 2006 Syndemics, Sex and the City: Understanding Sexually Transmitted Disease in Social and Cultural Context. Social Science and Medicine. 63(8):2010-2021.
Singer, M. and Clair, S. 2003 Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context. Medical Anthropology Quarterly 17(4): 423-441.
Soule, J., Olyaei, A., Boslaugh, T., Busch, A., Schwartz, J., Morehouse, S., Ham, J., and Orloff, S. 2005 Hepatitis C Infection Increases the Risk of New-onset Diabetes after Transplantation in Liver Allograft Recipients. American Journal of Surgery 189(5):552-557.
Stall, R., Mills, T., Williamson, J., and Hart, T. 2003 Association of Co-occurring Psychosocial Health Problems and Increased Vulnerability to HIV/AIDS Among Urban men who have Sex with Men. American Journal of Public Health. 93(6).
Visnegarwala, F., Chen, L., Raghavan, S., and Tedaldi, E. 2005 Prevalence of diabetes mellitus and dyslipidemia among antiretroviral naive patients co-infected with hepatitis C virus (HCV) and HIV-1 compared to patients without co-infection. Journal of Infection. 50(4):331-7.
Wasserheit, J. 1992 Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sexually Transmitted Disease 19:61
Syndemics
This blog is dedicated to promoting the study and discussion of syndemics. There term "syndemics" was coined to support a new perspective on health and disease. The traditional biomedical approach to disease is characterized by an effort to treat labeled health conditions liked diabetes or AIDS as if they were distinct entities in nature, separate from other diseases, and independent of the social contexts in which they are found. Historically, this approach proved to be very useful in focusing medical attention on the immediate causes and expressions of disease and it contributed to the emergence of modern biomedical treatments, some of which have been enormously successful. As the compendium of health knowledge has advanced, however, it has become increasingly clear that diseases do not necessarily exist in isolation from other diseases and other health conditions, rather interactions among diseases are of considerable importance to disease course and consequence, and that the social conditions of disease sufferers are absolutely critical to understanding health at the individual and population levels. Rather than existing as discrete conditions, multiple life-threatening diseases often are concentrated in particular populations. In a word, diseases, tend to cluster.
Beyond disease clustering, there is growing evidence of important interactions among comorbid diseases. One such interaction has been found, for example, between type 2 diabetes mellitus and various infections, such as hepatitis C viral infection in women. The worldwide prevalence of type 2 diabetes has been increasing and now impacts the lives of millions of women around the globe. Various factors are recognized as contributing to the onset of type 2 diabetes, including obesity and aging. The role of infection, however, is only beginning to be recognized. Already it is clear that risk for serious infections of various kinds increases significantly with poor diabetes control, but appreciation of more complex relationships between infection and type 2 diabetes is now emerging as well (Soule et al. 2005, Visnegarwala 2005). The NHANES III found that type 2 diabetes increases among people who have been infected with the hepatitis C virus. (O’Connor et al. 2004). Similarly, several health reports note that diabetes is present in as many as 37% of those who are critically ill with severe acute respiratory syndrome (SARS) (Booth et al. 2003, Fowler et al. 2003). These examples suggest the importance of dynamic diabetes/infection linkages. It is disease interactions of this sort that are a central element in syndemics. Syndemic theory seeks to draw attention to and provide a framework for the analysis of these interactions.
Various syndemics (although not always labeled as such) have been described in the literature already, including the SAVA syndemic (substance abuse, violence and AIDS) (Singer 1996, 2006), the hookworm, malaria and HIV/AIDS syndemic (Hotez 2003), the Chagas disease, rheumatic heart disease and congestive heart failure syndemic (Cubillos-Garzon et al. 2004), the asthma and infectious disease syndemic (Johnson and Martin 2005), the malnutrition and depression syndemic (Heflin, Siefert and Williams 2005), and the mental health and HIV/AIDS syndemic (Stall et al. 2003). Additionally, several syndemics have been identified that involve sexually transmitted diseases (Chesson et al. 2005, Craib et al. 1995, Otten et al. 1994). Here too, researchers report interactions between comorbid STDs and other diseases (Nusbaum et al. 2004).
Beyond disease clustering and interaction, the term syndemic also points to the importance of social conditions in disease concentrations, interactions and consequences. In syndemics, the interaction of diseases or other health problems (e.g., malnutrition) commonly arises because of adverse social conditions (e.g., poverty, stigmatization, oppressive social relationships) that put socially devalued groups at heightened risk. As Farmer (1999) argues with reference to TB, it is impossible to understand its persistence in poor countries as well as its recent resurgence among the poor in industrialized countries without assessing how social forces, such as political violence and racism, come to be embodied and expressed as individual pathology.
The purpose of syndemic theory is to facilite reconception and the way that we look at, think about, and respond to disease. In nature a parallel phenomenon to syndemics is seen in the case of lichens. Lichens are not a kind of species or other higher or lower level taxa as we usually use those terms, rather they are symbiotic partnerships between a fungus and either algae or cyanobacteria. As Chadwick (2003:119) comments, “I think of lichens as kind of a doorway between organisms [or individual species] and ecosystems. Look out one direction, and you see individual things; look the other way, you see processes, relationships—things together. This is the new level in understanding biology.”
As Chadwick notes (1992/93:1), “If we continue to focus chiefly on species -- even though we embrace all shapes and sizes of them -- rather than on connections, our view of nature will remain incomplete. So will our efforts at protection.”
Beyond disease clustering, there is growing evidence of important interactions among comorbid diseases. One such interaction has been found, for example, between type 2 diabetes mellitus and various infections, such as hepatitis C viral infection in women. The worldwide prevalence of type 2 diabetes has been increasing and now impacts the lives of millions of women around the globe. Various factors are recognized as contributing to the onset of type 2 diabetes, including obesity and aging. The role of infection, however, is only beginning to be recognized. Already it is clear that risk for serious infections of various kinds increases significantly with poor diabetes control, but appreciation of more complex relationships between infection and type 2 diabetes is now emerging as well (Soule et al. 2005, Visnegarwala 2005). The NHANES III found that type 2 diabetes increases among people who have been infected with the hepatitis C virus. (O’Connor et al. 2004). Similarly, several health reports note that diabetes is present in as many as 37% of those who are critically ill with severe acute respiratory syndrome (SARS) (Booth et al. 2003, Fowler et al. 2003). These examples suggest the importance of dynamic diabetes/infection linkages. It is disease interactions of this sort that are a central element in syndemics. Syndemic theory seeks to draw attention to and provide a framework for the analysis of these interactions.
Various syndemics (although not always labeled as such) have been described in the literature already, including the SAVA syndemic (substance abuse, violence and AIDS) (Singer 1996, 2006), the hookworm, malaria and HIV/AIDS syndemic (Hotez 2003), the Chagas disease, rheumatic heart disease and congestive heart failure syndemic (Cubillos-Garzon et al. 2004), the asthma and infectious disease syndemic (Johnson and Martin 2005), the malnutrition and depression syndemic (Heflin, Siefert and Williams 2005), and the mental health and HIV/AIDS syndemic (Stall et al. 2003). Additionally, several syndemics have been identified that involve sexually transmitted diseases (Chesson et al. 2005, Craib et al. 1995, Otten et al. 1994). Here too, researchers report interactions between comorbid STDs and other diseases (Nusbaum et al. 2004).
Beyond disease clustering and interaction, the term syndemic also points to the importance of social conditions in disease concentrations, interactions and consequences. In syndemics, the interaction of diseases or other health problems (e.g., malnutrition) commonly arises because of adverse social conditions (e.g., poverty, stigmatization, oppressive social relationships) that put socially devalued groups at heightened risk. As Farmer (1999) argues with reference to TB, it is impossible to understand its persistence in poor countries as well as its recent resurgence among the poor in industrialized countries without assessing how social forces, such as political violence and racism, come to be embodied and expressed as individual pathology.
The purpose of syndemic theory is to facilite reconception and the way that we look at, think about, and respond to disease. In nature a parallel phenomenon to syndemics is seen in the case of lichens. Lichens are not a kind of species or other higher or lower level taxa as we usually use those terms, rather they are symbiotic partnerships between a fungus and either algae or cyanobacteria. As Chadwick (2003:119) comments, “I think of lichens as kind of a doorway between organisms [or individual species] and ecosystems. Look out one direction, and you see individual things; look the other way, you see processes, relationships—things together. This is the new level in understanding biology.”
As Chadwick notes (1992/93:1), “If we continue to focus chiefly on species -- even though we embrace all shapes and sizes of them -- rather than on connections, our view of nature will remain incomplete. So will our efforts at protection.”
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