What are syndemics, and why do they matter in health governance?
The era of COVID-19 has indisputably taught us the importance of viewing health and socioeconomic factors as mutually reinforcing. The past years have highlighted how health crises are not only biomedical phenomena but rather intrinsically encompass political, social, cultural and economic dimensions. Future health governance could serve its purpose with more zeal and efficiency if it started to account for ’syndemics’.
The term syndemic describes a situation in which two or more health and social factors are clustered together, and their interaction further worsens the community’s overall health. Introducing this term in our thinking allows us to view these factors as interlinked and mutually reinforcing — instead of parallel but separate epidemics. Consequently, syndemic theory explains why we observe an accumulation of health and social problems in specific populations or groups.
Focusing on vulnerable populations
By studying the concurrent epidemics of addictions, poverty, violence and HIV/AIDS, Merrill Singer (1996) noted that these health and social issues were interrelated and influenced each other. According to Singer, a syndemic occurs when
- two or more diseases or health conditions are clustered together,
- these conditions worsen each other and increase the overall health burden, and
- there are social conditions, such as social isolation and poverty, which create conditions for clustering and synergistic interaction.
Syndemic theory invites us to ask why a specific clustering occurs in a particular population rather than viewing health from the perspective of an individual. The theory emphasises that health and social problems accumulate among those already in marginalised and impoverished positions. As a result, syndemics inherently reveal structures of power and privilege.
Syndemic theory has evolved to account for cumulative health risks and socioeconomic conditions that could make specific populations more vulnerable. For instance, the VIDDA syndemic (Mendelhall, 2012) refers to the interconnections of violence, immigration/isolation, depression, diabetes and abuse among Mexican women living in the United States. When combining structural stressors such as systemic violence, poverty and immigration with adverse relationship factors such as interpersonal abuse, Mexican immigrant women are more likely to develop diabetes and depression than the overall population.
Syndemic theory has sometimes been criticised for ignoring the underlying structural causes of health and social problems. For instance, Sangaramoorthy & Benton (2021) call for adopting an intersectional lens to increase our understanding of what makes particular populations vulnerable; increased awareness of these underlying conditions and structures would allow policymakers to design measures to diminish the syndemic effects.
The COVID-19 pandemic aggravated other social and health problems
The COVID-19 pandemic has clearly revealed the interconnection of health and social problems. By viewing COVID-19 as a syndemic, we can rethink our approach to current and future health crises. In our real-world context, instead of a variety of parallel health and social problems creating a syndemic, the contagious disease was added to the pre-existing constellation of social and health issues.
The past years have also highlighted that a strictly medical response and its traditional indicators do not provide enough information about the societal consequences of an infectious disease (Boes et al., 2021). Instead of limiting the governmental response to the imminent health implications, the syndemic approach extends that response to other policy areas such as education, employment, housing, food, and the environment.
Mainstreaming syndemics thinking within public debates can also help us understand the implications of health crises on different populations and, as a result, foster empathy. In research, using syndemic theory to guide collecting, combining and analysing data has been instrumental in showcasing the inequity of social conditions. Not everyone has experienced the pandemic with an equal sense of danger. For example, being outside the home during a quarantine and risking higher exposure to COVID-19 has been misinterpreted as disorderly conduct, even though it has often been driven by the sheer necessity of earning a living for those who are not able to work from home (see e.g. Griffith et al., 2021).
The policies aiming to tackle the spread of COVID-19 have also created conditions for the accumulation of other socioeconomic problems. For instance, while maintaining the remote work policy for two consecutive years might have been an effective measure to prevent the spreading of the virus, it has spurred a mental health epidemic that is likely to unfold during the coming years. Additionally, the pandemic restrictions have led to temporary unemployment in some low-paying occupations, such as the service industry, where employees might have fewer savings for these unexpected events such as lay-offs.
Although health crises often escalate other societal problems, they can also have surprising positive consequences. For instance, the slight decrease in CO2 emissions at the beginning of the pandemic led to improved air quality in many regions. In Europe, the enhanced air quality decreased air pollution-related deaths and proved that it is possible to cut down greenhouse gas emissions rapidly. The pandemic also enabled an unforeseeably fast socio-technical transition for knowledge workers as organisations had to transition into remote work overnight.
How can we build resilient health governance in the future?
Firstly, to improve societal wellbeing after the pandemic, it is essential to identify and locate the underlying social and health-related problems that the pandemic and its related policies have been reinforcing. However, shortcomings in the national-level data collection efforts can make the application of syndemic theory challenging, as has been the case in Finland.
Secondly, we need to find avenues for collaboration between different social and health sciences. Adopting a syndemic approach poses multiple challenges to decision-making as the extra dimensions are bound to have incommensurable governance demands. As it entails combining knowledge from various stakeholders representing a versatile set of ideologies, it leads to the question of how political decision-makers value different sources of knowledge.
Lastly, responding to future health crises will require increased institutional resilience in health governance. This means less siloed governance with increased communication and coordination between different actors. While enhancing cooperation between various public institutions improves the resilience of the public crisis management infrastructure, it is likely to decrease efficiency — which policymakers often prioritise when evaluating the success of governance measures.
When analysing health crises such as COVID-19, the syndemic is an illustrative concept for policymakers as it helps to describe the interlinkages between different health and societal dimensions. It can also encourage public servants to explore new tools, skills and structures required to locate these interlinkages. Therefore tuning into the syndemic nature of crises may initiate a learning process, which at its best, can lead to a more profound systemic change.
The original version of this article was published on Demos Helsinki’s website.