Nicola Bulled’s research while affiliated with University of Connecticut and other places

Syndemic theory posits that co-occurring diseases interact in a manner that increases disease transmission, progression, and negative health outcomes. And that adverse socioeconomic and environmental conditions promote this disease or health condition clustering and interaction. The concept offers two important contributions to the health sciences. First, it positions socioeconomic, structural, and environmental conditions as central to disease burdens. Second, as a portmanteau – ‘syn’ for synergy and ‘demic’ for disease epidemics – syndemic theory indicates that in some cases diseases do not merely co-occur but synergistically interact to affect an outcome that is more than the accumulation of the individual disease effects. The difficulty in operationalizing these central elements has resulted in a divergence of scholarship from the centralizing principles of the theory towards a simpler accumulation perspective in which more conditions equate to worse health outcomes. In addition, all empirical syndemic assessments should include robust qualitative assessments of the dynamics, however, much syndemic scholarship focuses only on quantitative analyses. To address these issues, a five-step approach to quantitative analyses of syndemic arrangements is proposed: (1) identifying disease clusters within a defined population; (2) determining the relevant social and structural factors that support disease clustering; (3) determining if clusters are distinct by social/demographic groups within the population; (4) evaluating if the identified disease cluster contributes to worse health outcomes; and (5) assessing for synergy between clustering diseases. This stepwise strategy ensures not only a rigorous assessment of hypothesized syndemic interactions but also presents a closer alignment of scholarship with syndemics theory. As an illustration, the approach is applied to an assessment of a hypothesized HIV/cardiovascular disease syndemic in South Africa. While syndemics theory has proven valuable in guiding public health interventions and policy, progressive improvement must be made in the application of the theory to ensure that it continues to effectively inform comprehensive practice.

Occupational exposures in the large industrial mining sector contributed significantly to South Africa’s high excess death rate due to COVID-19. Historically poor work-protection oversight has perpetuated centuries of risky labor and living conditions within the industry, driving high levels of disease co-morbidities, and supporting enduring social vulnerabilities. In this paper, we offer a syndemic lens to consider the clustering of adversely interacting diseases among mineworkers in South Africa, drawing attention to the complex occupational health crisis and the need to move beyond simply reporting individual diseases or comorbidities among this population. The physically demanding and dangerous working conditions, the lack of adequate changes to crowded and unsanitary working and living situations, the failure to meet social and labor plan targets, the continued precarious nature of working contracts and mines, and the limited access to robust healthcare reflect the historically exploitative nature of industrial mining in South Africa that places miners at increased risk for various syndemics. This assessment of the adverse interactions of diseases and socioeconomic and political conditions highlights the need for focused research and more follow-through in comprehensive occupational reforms.

This book focuses on syndemics in the Global South and uses COVID‑19 as a window to understand clusters of disparities and disease comorbidities. The pandemic has exposed and multiplied structural inequalities and certain subpopulations were more exposed to COVID‑19 as well as experienced greater morbidity and mortality. The effects of the pandemic differ between countries but have had an especially major impact, although in varying ways, in the Global South. The contributions in this volume explore the differential impacts of COVID‑19 at individual, community, national, or regional levels, considering how structural violence is institutionalized in a way that creates vulnerable situations and disproportionate suffering. The book will be of interest to anthropologists and sociologists as well as to those working in global and public health.

Background COVID-19’s heavy toll on human health, and its concentration within specific at-risk groups including the socially vulnerable and individuals with comorbidities, has made it the focus of much syndemic discourse. Syndemic theory recognizes that social factors create the conditions that support the clustering of diseases and that these diseases interact in a manner that worsens health outcomes. Syndemics theory has helped to facilitate systems-level approaches to disease as a biosocial phenomenon and guide prevention and treatment efforts. Despite its recognized value, reviews of syndemics literature have noted frequent misuse of the concept limiting its potential in guiding appropriate interventions. Objective To review how the term ‘syndemic’ is defined and applied within peer-reviewed literature in relation to COVID-19. Design A scoping review of definitions within COVID-19 literature published between January 1, 2020 to May 15, 2023 was conducted. Searches took place across six databases: Academic Search Premier, CINAHL, JSTOR, MEDLINE/Pubmed, PsycINFO and Scopus. PRISMA-ScR guidelines were followed. Results Content analysis revealed that COVID-19 has varied clustered configurations of communicable–non-communicable diseases and novel communicable disease interactions. Spatial analysis was presented as a new strategy to evidence syndemic arrangements. However, syndemics continue to be regarded as universal, with continued misunderstanding and misapplication of the concept. Conclusion This review found that current applications of syndemics remain problematic. Recommendations are made on the design of syndemic studies. A syndemic framework offers an opportunity for systems-level thinking that considers the full complexity of human-disease interactions and is useful to inform future pandemic preparations and responses.

Nearly one in five U.S. adults are impacted by long Covid. The health, social, and economic burdens of long Covid are complicated and trying. Although the causes of long Covid remain uncertain, emerging research suggests an infectious disease origin for at least some portion of cases. We draw on a grey and white literature, media reports, and postings on forums to examine the shared experiences of long Covid and the present argument for pathogen-pathogen interactions. Data suggest that long Covid disproportionately impacts communities that already experience disparities in health, specifically lower-educated, low-income, women of working age and minority ethnic groups as they have greater exposure to COVID-19 initially and experience the symptoms of long Covid more severely. Among these individuals, COVID-19 can play a role in reactivating viruses already present in the body (specifically herpesviruses) which accumulate over the course of a lifetime and generally persist in a dormant state. As such, long Covid may present as a syndemic in some communities – the clustering of synergistically interacting diseases, a consequence of deleterious social conditions. The syndemic nature of long Covid requires a syndemic response to address the intersecting social and biological drivers. At the population level, considerations of the social factors, disease co-morbidities including those dormant or yet to be diagnosed, need to be integrated into treatment protocols and public health responses.

Refugees use social networks to navigate the institutions of immigration. Social networks also serve as support structures as refugees claim their identity and establish a sense of belonging. This paper examines the influence of personal social networks on the integration experiences of 16 asylum‐seekers in Thessaloniki, Greece. Case studies of three recent asylum‐seekers convey how the dynamics of personal social networks differentially influence the experiences of integration. The visualizations of their personal social network, the 45 individuals they engage with routinely, reveal the structure and composition of their social lives. Across the study sample, refugees with more Greek contacts were better able to navigate the economic and legal landscape. However, more engagement with host nationals did not necessarily improve feelings of belonging. Migration policies and programming should consider how to use social networks, both existing and new, to improve migrant integration outcomes.

Global health leaders evoked the concept of "solidarity" to unite citizens in efforts to contain the COVID-19 pandemic. Historically the term has been used in different domains (politics and labor) and in connection to different crises (refugees, immigration, and climate change). Was "solidarity" a useful rallying cry? To assess the impact of health communication efforts to motivate citizen action, surveys were administered at three key moments in the first two years of the pandemic: June 2020 as cases declined globally (n = 90); October 2020 during the second wave of infections in Europe and the US (n = 96); and March 2021 when vaccines became available to adults (n = 100). Calls for solidarity motivate fleeting efforts, irrespective of perceived risk, and are less likely to inspire action for the public good as compared to other motivators such as team reasoning and compassion. While the pandemic revealed the capacity of citizens to support one another in the absence of state intervention, calls for solidarity are ineffective in inspiring long-term engagements toward a common good.