Pushing the Syndemic Research Agenda Forward: a Comment on Pitpitan et al

Dr. Merril Singer, a medical anthropologist, first introduced the concept of a syndemic in the mid-1990s to describe the co-occurrence and interactions between two or more diseases to disproportionately impact the health and well-being of marginalized communities [1, 2]. Unlike the traditional medical model that attempts to isolate the causes of diseases by controlling for potential confounders such as poverty, the syndemic approach considers the important role that social determinants of health play in not only contributing to the emergence of diseases, but also exacerbating the effects of these diseases on the health and well-being of vulnerable communities [3, 4]. This approach therefore appears to be especially promising in retooling our public health efforts to address health disparities both within a national and global context. In their study entitled, “Co-Occurring Psychosocial Problems and HIV Risk Among Women Attending Drinking Venues in a South African Township: a Syndemic Approach,” Pitpitan et al. help advance the syndemic research agenda on various fronts [5]. First, they applied the syndemic framework to expand our understanding of factors that contribute to one of the most health disparate conditions, HIV, within a very vulnerable group, women in South Africa. Through their study, Pitpitan et al. expanded on what was known about syndemics associated with HIV by documenting the close relationships that exists between HIV and a myriad of social and psychological conditions within one of the most vulnerable regions of the world. These conditions included food insufficiency, depression, posttraumatic stress disorder, childhood and adult abuse, drug use, and alcohol problems [5]. Second, Pitpitan et al. advanced our knowledge about how syndemics work to disproportionately impact the health and well-being of a community. In doing so, they uncovered a dose–response relationship between the number of psychosocial conditions present and the mean number of unprotected sexual acts. This finding suggests that in order to reduce risk for HIV among women in South Africa, a syndemic-oriented intervention that addresses food security and mental health is needed. The more comprehensive the approach is addressing this complex cluster of conditions, the more promise it appears it would have in decreasing HIV risk. Despite the progress that has been made in syndemic oriented research, there are several areas that must be addressed to continue to move the research agenda forward. First, funding for syndemic-oriented research needs to be available. This is already beginning to become evident. In fact, a search of the National Institute of Health Reporter System using the search term “syndemic” yielded nine studies or centers currently being funded with this term in the title [6]. Nevertheless, given that NIH is mostly organized according to independent diseases or health conditions, opportunities to support syndemic research are not always clear to investigators. Second, syndemic research needs to further elucidate the cause and effect pathways between social determinants of health, disease sequelae, and how these diseases interact with one another and the social context to exacerbate health disparities. Therefore, more etiological research is needed. Finally, syndemically oriented intervention research is needed across all levels of prevention. This includes developing and evaluating prevention strategies that: (1) address social inequities that serve as the breeding ground for health disparities, (2) screen for the co-occurrence of diseases and social conditions that can exacerbate health disparities, and (3) comprehensively treat the health and social maladies experienced by health disparities populations. By developing intervention strategies that are guided by a syndemic orientation, we are likely to increase the cost effectiveness of our efforts to eliminate health disparities [7].