Elsevier

The Lancet

Volume 389, Issue 10072, 4–10 March 2017, Pages 951-963
The Lancet

Series
Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations

https://doi.org/10.1016/S0140-6736(17)30402-6Get rights and content

Summary

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.

Introduction

This Series paper investigates syndemics involving non-communicable diseases (NCDs) to show the complexities through which social, psychological, and biological factors come together to shape emergent and pervasive global health problems. Syndemic refers to the clustering of two or more diseases within a population that contributes to, and results from, persistent social and economic inequalities.1 The concept focuses on instances in which multiple health problems interact, often biologically, with each other and the sociocultural, economic, and physical environment.1, 2 For example, in the mid-1990s, the anthropologist Merrill Singer2, 3, 4, 5, 6 explored how substance abuse, violence, and AIDS cluster together and affect one another among an impoverished inner-city population in the USA; he coined the term SAVA syndemic to describe this process. By recognising how these mutually interacting factors promote adverse health outcomes, the syndemic framework moves beyond disease-specific or multimorbidity models to evaluate how social and economic conditions foster and exacerbate disease clusters.7, 8 Syndemics provide a tool for empirically evaluating how health statuses of multi-morbidity arise in a population, and what health interventions might be most effective for mitigating them.

We focus on type 2 diabetes and discuss how mental illness and infectious disease can cluster with metabolic conditions in both high-income countries (HICs) and low-income and middle-income countries (LMICs). As obesity and other NCDs such as diabetes, hypertension, and heart disease escalate in LMICs, these conditions become more prevalent among low-income populations, shifting from the affluent to the less affluent.9 Although there are recognised global transformations in obesity, food practices, and activity patterns,10 this does not ensure that universal one-size-fits-all interventions will be effective across populations. We argue that contextual factors matter, because people experience diabetes differently across social contexts, and this affects how diabetes becomes syndemic. This framework is exemplified in scholarship on syndemic suffering that has employed empirical analysis of individual-level experiences of syndemic interaction to show how social problems that cluster with diabetes and depression differ across contexts.7, 11, 12 For instance, immigration-related stress is central to the mental health of many Mexican immigrant women with diabetes who have undocumented family members or are themselves undocumented.7 This mental stress differs from women residing in the same communities with different ethnic and legal statuses, such as Puerto Ricans and African Americans.8 A syndemic approach can then be applied to design integrated chronic care that can be locally relevant and most effective at mitigating the root causes of co-occurring conditions in public health and medicine.13

Key messages

  • Non-communicable diseases share common risk factors resulting in escalation of comorbidities, especially among low-income, marginalised populations worldwide

  • The clustering of social and health problems is often overlooked in social epidemiology and other models of epidemiological transition

  • Syndemic care requires that we recognise how social problems cluster with and affect medical problems, and that co-occurring diseases can present differently than singular disorders

Our goal is to examine how syndemic approaches previously limited to socially and economically disadvantaged populations in HICs could be expanded to apply to conditions in LMICs. We triangulate research from medicine, public health, and anthropology to illustrate how poverty, depression, and diabetes cluster in the low-income populations in HICs, and we illuminate the various facets of their interaction. We bring this discussion to LMIC contexts and discuss diabetes comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Considering how social and health problems cluster together and mutually exacerbate one another differently across contexts is an indispensable way in which we can frame, understand, and treat NCDs. Through a syndemic orientation, global health practitioners can recognise in their clinical practice and community-based intervention how social, cultural, and political factors facilitate disease clusters and escalate morbidity and mortality.

Section snippets

Principles of syndemic theory

Syndemic theory provides a framework to advance medicine, health systems, and human rights by bringing multiple fields together to recognise, describe, and appropriately intervene in the complex multiple disease burdens that afflict susceptible populations. We describe how syndemic theory enables us to: recognise biological interactions between co-occurring conditions that can belie the true interaction of two or more conditions; describe under what circumstances two or more medical conditions

Diabetes syndemics in rapidly transitioning economies

Syndemics provide an important alternative to NCD epidemiology because the framework addresses how social conditions affect the emergence and medical outcomes related to NCDs such as diabetes, cancer, stroke, and mental illness. Broadly, epidemiologists have shown that rapid economic growth has contributed to demographic, nutrition, and health transitions that have extensively shaped the incidence and prevalence of obesity.9, 61 Such transitions come together through technological innovations,

Application of syndemic models to improve global health

The syndemic framework can have a measurable effect on health care and quality of life when applied to public health and clinical medicine. Syndemics render prevention and intervention programmes more successful when addressing the multiple disorders and specific contextual vulnerabilities holistically, rather than viewing the disorders individually or as extractable from the context in which they occur (as shown by models for syndemic care, Panel 1, Panel 2, Panel 3).5 Indeed, there are many

Recommendations and steps forward

We recommend that a syndemic framework be adopted as a tool for recognising, researching, testing, evaluating, and implementing integrated health programmes, especially those dealing with multiple chronic conditions. First, researchers and care providers must recognise how social and medical problems cluster and interact within certain populations. Understanding what social problems affect certain disease clusters across geopolitical contexts and within specific regions and populations is

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