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Health Studies
Rhan- Ju Song

HLTC05: Social Determinants of Health Lecture 8 –Syndemics: Culture and Biology Intertwined (Reitmanova and Gustafson 2011 and Singer and Clair 2003) Tuesday, October 30, 2012 Syndemic (Baer et al. 1997; Singer 1996)  Term introduced by medical anthropologists  The synergistic interaction of two or more co-existent diseases or health conditions (e.g., malnutrition, stress) that result in excess burden of disease o Illness manifestation that person suffers o MORE morbidity when you are dealing with co-morbidity with diseases rather than suffering from two individual disease  A set of intertwined and mutually enhancing diseases/epidemics involving disease interactions at the biological level that develop and are sustained in a community because of harmful social conditions and injurious social connections/relationships (structural violence) o Allows syndemics to strive within structural violence  Interaction of culture and biology Recognized Syndemics  Asthma and co-infection with RSV (respiratory syncytial virus) and influenza A virus....asthma exacerbation (note consistent association of SES, violence with asthma severity, mortality, esp. among inner-city kids)  Hepatitis C and HIV  Hep C, HIV and alcohol abuse, with subsequent liver disease/cancer  Violence victimization, drug use and AIDS  Sexual abuse as a child (type of violence victimization), drug use and hepatitis C/skin abscesses/STDs/drug overdoses/pneumonia/mental illness SAVA  Urban settings: interactions of Substance Abuse, Violence (street/domestic) and AIDS (SAVA)  Singer (1996: 99): in inner-city, low-income communities, substance abuse, violence and AIDS "are not merely concurrent, in that they are not wholly separable phenomena. Rather, these three closely linked and interdependent threats to health and well being... constitute a major syndemic that already has taken a devastating toll" o Higher rate of SAVA marked by poverty  Intravenous drug use (IDU) and disease..... Of HIV-infected IDU individuals, in 91% of cases: coexistence of at least one other major disease o e.g., hepatitis, TB, endocarditis, STDs, pneumonia, diabetes, liver disease or mental illness (Singer and Clair 2003)  43% of HIV-infected individuals suffer from 3 or more of these diseases o Tied to the social conditions people are living in  Those with high number of diseases more likely to be homeless (an important predictor of death from AIDS) Syndemics at the Population Level (level 1)  Two or more epidemics (i.e., notable increases in the rate of specific diseases in a population), interacting synergistically and contributing, as a result of their interaction, to excess burden of disease in a population  When social conditions foster multiple disease expression in the same location / population, syndemics will arise o Tied to location which can foster disease such as sexually transmitted disease Syndemics at the Biological Level  Biological synergism: happening within the person  In cases of co-affliction with two or more diseases, actual biological interaction occurs (Singer and Clair 2003)  Nature of this interaction varies and does not require direct physical interaction to produce new or amplified health consequences (e.g., changes in biochemistry or damage to organ systems caused by one pathogenic agent may facilitate spread or impact of another agent)  However, very direct interaction, including gene mixing among pathogenic agents, has been observed  Influenza virus and pneumococcus....can result in excess mortality from secondary bacterial pneumonia during flu epidemics (McCullers and Rehg 2002)  Co-infection of Hepatitis B virus (HBV) and HIV - a significant example of biochemical changes produced by one pathogen contributing directly to the harmful impact of a second pathogen, in this case allowing accelerated replication of the second agent (see Singer and Clair 2003)  Recent research indicates that HBV can infect T-lymphocytes, the primary cellular target of HIV, suggesting that HBV and HIV may come into direct physical contact at the cellular level in co-infected individuals (see Singer and Clair 2003) Syndemics at the Social Context Level  Beyond the notion of disease clustering in a location or population, and processes of biological synergism among co- dwelling pathogens, the term syndemic points to the determinant importance of social conditions in the health of individuals and populations (Singer and Clair 2003)  Reflect bio-cultural  Impacts of disease co-infection are mediated by individual biology, age, sex, but also nutritional status, SES, access to health care  Sociopolitical context of sufferers' health is critical o Social context is the root cause, Think about social conditions, Lethal to communities Social Conditions as Risk Factors  Poverty: allows syndemic to rise o Malnutrition o Higher likelihood of pre-existing immune system damage from other infections and malnutrition (and subsequent poor effectiveness of available treatments) o Overcrowding in poorly ventilated dwellings, homeless shelters; multiple exposures to pathogens o Poor access to diagnosis and treatment o Reduced ability to adhere to treatment plans because of structurally imposed residential instability and disruptive economic and social crises in poor families o Stigmatization, racism, sexism, ostracism  They don’t have a voice Malnutrition  Compromised immune systems and greater vulnerability to infections  Higher likelihood of influenza, with greater lethality, organ involvement, duration  Normally harmless virus coxsackie B3 – can lead to life-threatening heart disease in malnourished adults (those deficient in selenium)  Poverty, childhood malnutrition and later heart disease (Barker and Osmond 1986, England and Wales), associated with adult diet high in cholesterol  Malnutrition, TB and HIV co-infection  “Poor diet is one of the direct routes through which social conditions and inequality impact health and contribute thereby to syndemical enhancement of disease” Singer and Clair 2003: 429 Stress  A common consequence of poverty, discrimination and other forms of social suffering (Blakey 1994, 2001; Dressler 2003; Goodman 2001; Leatherman 2001; Leatherman and Daltabuit2 001; McDade 2002)  Another primary route through which oppressive social conditions find expression in clinical outcomes  Increased blood pressure, cardiovascular disease, delayed growth & development, impaired fertility, chronic fatigue, depression, anxiety, migraines, eating & sleeping disorders, more rapid disease progression, etc.  Compromised immune systems and greater vulnerability to infections Stress  Living environment (physical, social, emotional)  Employment / lack of  Changing conditions  From racism, sexism, ostracism, stigmatization  Stigma: another important pathway linking social relations and health status (source of stress)  Significant barrier in access to public health, health- and treatment-seeking behaviours, compliance The Process of Stress  Prolonged exposure  Increasingly straining the body from defending itself  Issue of constant pressure Anthropogenesis of Syndemics  “To think syndemicly about infectious diseases means unraveling the biological, social, and historical connections which shape the distribution of infections over space and time.  According to Herring and Swedlund (2010: 6), exposing these historical connections allows scholars ‘to explore larger environments of risk and historically contingent social structures that converge to produce disproportionately infected spaces for some, but not all, members of society.”  Syndemics affects population disproportionally o Reitmanova and Gustafson 2012: 405  The appearance of syndemics reflect breakdowns in social infrastructure, fragmentation of public health efforts and gaps in health care delivery (Singer and Clair 2003: 431)  To prevent a syndemic, one must not only prevent or control each disease but also the forces that tie those diseases together (Milstein 2001)  Recognize the social forces that create these infection Syndemics  HIV leads to: 1. Increased susceptibility to TB 2. Reactivation of latent TB 3. Acceleration of active TB Re-emergence of Disease  Innate biological aspec These factors of human made causes  The interaction of: 1) Social change 2) Demographic change 3) Environmental change 4) Microbial adaptation Tuberculosis  syndemic with HIV  Can affect other parts of the body  Chronic disease of Mycobacterium bacteria  Respiratory condition  In humans, originated w/ population aggregation o Agriculture and close interaction and living with people cause the emergence of this disease  Spread by coughing/touch (Fomite: disease organism that can continue to live on an inanimate object)  Only 5-10% of those in contact with bacillae will develop TB  Most cases of active TB from adult re-activation from earlier childhood exposure (BCG vaccine), at times of stress  Once inhaled: focuses in the lung, body responds by developing a granuloma to wall off the bacillae –a Tubercle  Chronic cough (blood), fever, chills, weight loss, fatigue, pneumonia and lung infection  With flare-up, bacillae can spread throughout body, esp. areas of red blood cell production: ribs, vertebrae, pelvis, even skull  Found in the lungs  Can get cured or it may lay dormant until you die Hard Tissue Evidence  Spine gets eaten away by TB, as well as: (1) Vertebrae, (2) Hip, (3) Knee  Bone destruction not formation o Seen in mummies o Been with humans for a long time o Refer to consumption  consumes the body inside and outside Individuals at Risk  Friends/family of those w/active disease  Poor and medically underserved  Homeless people  Prisoners  Elderly  Those from countries with high incidence rates  Residents of care/nursing homes  Alcoholics and intravenous drug users  Those with pre-existing conditions, esp. HIV, or undergoing treatments that impair immune function  Health care workers and those in contact with high risk populations, e.g., prison guards TB Today  2 million deaths annually; 5000 die every day  98% TB deaths: developing/underdeveloped world (2004: ranked 4th in infectious disease mortality)  2 billion people, or 1/3 of the world's total population, are infected  approx. 9 million will develop the active disease annually  Today TB is a pandemic  across the world, especially in places that are impoverished and able to thrive  While the highest rates per capita are in Africa (a quarter of all TB cases), half of all new cases are in 6 countries: Bangladesh, China, India, Indonesia, Pakistan, Philippines o Past: be able to treat with 2/3 antibiotics o Need more drugs now to fight TB o Has become more resistance because of human made factors o Micro are evolving Drug Resistance  MDR-TB: multi-drug-resistant TB – when there is resistance to two of the most potent first-line TB drugs o In virtually all 109 countries recently surveyed by WHO o 425,000 new MDR-TB cases occur every year with the highest rates in the former USSR and China, where up to 14% of all new cases are not responding to the standard drug treatment  XDR-TB: extensively drug-resistant TB - resists treatment by three of the six second-line drugs (or one of the three injectable second-line drugs) after all first-line drugs fail o First detected in 2006
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