Introduction to Syndemics

A Critical Systems Approach to Public and Community Health

Merrill Singer

• Publisher: Jossey-Bass
• Year: 2009
• ISBN:
  9780470483008
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This book explains the growing field of syndemic theory and research, a framework for the analysis and prevention of disease interactions that addresses underlying social and environmental causes. This perspective complements single-issue prevention strategies, which can be effective for discrete problems, but often are mismatched to the goal of protecting the public's health in its widest sense.

"Merrill Singer has astutely described why health problems should not be seen in isolation, but rather in the context of other diseases and the social and economic inequities that fuel them. An important read for public health and social scientists."
— Michael H. Merson, director, Duke Global Health Institute

"Not only does this book provide a persuasive theoretical biosocial model of syndemics, but it also illustrates the model with a wide variety of fascinating historical and contemporary examples."
— Peter J. Brown, professor of Anthropology and Global Health and director, Center for Health, Culture, and Society, Emory University

"The concept of syndemics is Singer's most important contribution to critical medical anthropology as it interfaces with an ecosocial approach to epidemiology."
— Mark Nichter, Regents Professor, Department of Anthropology, University of Arizona

"Merrill Singer offers the public the most comprehensive work ever written on this key area of research and policy making."
— Francisco I. Bastos, chairman of the graduate studies on epidemiology, Fundacao Oswaldo Cruz

"Exquisitely describes how this new approach is a critical tool that brings together veterinary, medical, and social sciences to solve emerging infectious and non-infectious diseases of today's world."
— Bonnie Buntain, MS, DVM, diplomate, American College of Veterinary Preventive Medicine

"For too long the great integrative perspectives on modern biomedicine and public health disease ecology and social medicine-have remained more or less separate. In this innovative and provocative book, Merrill Singer develops a valuable synthesis that will reshape the way we think about health and disease."
— Warwick H. Anderson, MD, PhD, professorial research fellow, Department of History and Centre for Values, Ethics, and the Law in Medicine, University of Sidney

PART 1

INTRODUCING KEY CONCEPTS IN SYNDEMICS

Chapter One, “Learning from Lichen: Reconceptualizing Health and Disease,” which makes up Part One of this book, introduces the reader to the concept of syndemics and to the biosocial syndemic perspective on human health. Examining the syndemic perspective in a historical context, it describes the developing recognition that health and illness are shaped by multiple and complex factors, and it shows how the identification and study of syndemics has grown out of these far-reaching shifts in the ways that we conceptualize disease.

CHAPTER 1

LEARNING FROM LICHEN

Reconceptualizing
Health and Disease

After studying this chapter, you should be able to

• Locate the syndemic perspective within the evolutionary history of the scientific understanding of disease, including dilemmas encountered in meeting Robert Koch’s criteria when attempting to determine the cause of an infectious disease.

• Understand the syndemic approach as one that supersedes two limitations of conventional biomedical approaches to disease—reductionism and mind-body dualism.

• Recognize the fundamental importance of biosocial interconnections and relationships in syndemics theory.

• Explain why syndemics were often not recognized in the past.

• Explain how the consideration of social factors, such as social disparity, differentiates syndemic processes from the biomedical conception of comorbidity and also differentiates syndemics among humans from synergistic disease inter-actions among animals.

ON NOT PLANTING CUT FLOWERS: THE WEIGHT OF HISTORY

It was just a few decades ago, in the 1970s, that medical anthropology, the source discipline for the syndemics concept, was a new field. George Foster and Barbara Anderson, in laying out an analytical approach to health-related issues for this new field, suggested a structural division of medical systems into two components: a disease theory system and a health care system, defining the first component as the “beliefs about the nature of health [and] the causes of illness” that prevail within a particular medical system (Foster & Anderson, 1978, p. 37). It is these beliefs that I am concerned with here.

The historical pathway leading to the contemporary biomedical and public health understanding of disease causation is both long and intricate (Richardson, 1991). On the one hand it is part of the larger historical course leading from prescientific to scientific modes of thought, and on the other hand it runs from simple to more complex scientific understandings of what disease is and how it develops within bodies, within populations, and within social and environmental contexts. The syndemic orientation, although recent in expression, is in fact an outgrowth of the new way of thinking about the causes of sickness that emerged and caught hold in the mid-1800s in a process commonly referred to as the rise of germ theory. This approach led first to the biomedical and public health conception of the nature of both contagious and noncontagious diseases (and more recently to reexamination of the assumed differences between these two broad categories of disease). This point then—the transition to a modern biological understanding of disease—is the starting place for examining the syndemic perspective, in that, as noted by historian Daniel Boorstin, trying to understand the present or plan for the future without a sense of the past is like trying to plant cut flowers (McCullogh, 2005).

GERM THEORY AND THE BIOMEDICAL CONCEPTION OF DISEASE

A critical moment in theevolution of biomedicine occurred during the mid-nineteenth century. During this epoch the healing system that was to evolve into modern biomedicine underwent a profound transformation, as detailed in the following sections.

Health as Balance

Prior to the mid-nineteenth century and dating back to the era of ancient Greece, physicians commonly understood health in terms of the balance among bodily fluids known as humors. Most prominent among ancient Greek physicians was Hippocrates (circa 460-370 B.C.), a man often credited in the West with being the father of medicine. Rejecting the notion of disease as a divine punishment for violations of spiritual laws—a disease theory that long predates ancient Greece yet lives on in the modern world (as seen, for example, in some religious interpretations of the HIV/AIDS epidemic as God’s punishment of a sinful world)—Hippocrates and his peers believed that certain human moods, emotions, and behaviors were directly under the influence of blood, yellow bile, black bile, and phlegm (and that these humors were, in turn, linked to the four elements of fire, air, water, and earth in the natural environment). When these four humors were not in balance (a state called dyscrasia, or “bad mixture”), a person fell ill and remained so unless balance was restored through medical intervention. As Erickson (2008) notes, Hippocrates rationalized disease, thereby laying the foundation for the “biomedical understanding that diseases—both individual . . . and epidemic . . . are natural processes not supernatural punishments” (p. 25).

The humoral notion of disease causation was elaborated further by another ancient physician, Galen (circa 131-200 A.D.), who stressed that understanding of disease must be based on experiential awareness of human anatomy and physiology. (Owing to a government ban on human dissection, Galen gathered his own knowledge of human anatomy, sometimes inaccurately, from examining the corpses of pigs, primates, and other animals.) Galen’s influence spread throughout the Western and Arab worlds and remained a factor in medical approaches to healing through the mid-1800s. As Hays (2000) observes, “Bleedings and purges . . . remained the order of the day for the early nineteenth century physician, however much he might have forsworn allegiance to Galenic humors” (p. 216).

Pollution Theory

Also important in historical thinking about disease causation, and reflective of the naturalistic and environmental understanding found in humoral theory, was the theory about the effects of miasma, or pollution theory. This understanding viewed toxic vapors given off by decomposing organic matter in the environment as the cause of many diseases. One such disease was malaria, believed to be caused by poisonous and foul-smelling environmental vapors arising from bodies of water found at low elevations and filled with particles of decomposed matter. This led European colonists in Africa, for example, to settle at high attitudes, a strategy that proved effective because it located the homes and offices of colonial administrators above the normal (temperature-sensitive) breeding elevation of mosquitoes, the real vectors of malarial infection. (Global warming and the resulting breeding of mosquitoes at ever higher elevations would make such a practice less effective today.)

Cholera in London From 1831 to 1833 and again from 1848 to 1849, London, then the most populous city in the world, experienced several epidemics of cholera. The name cholera is derived from the Greek term for bile and reflects that this water-borne disease was originally conceptualized as resulting from an imbalance of humors. However, in mid-nineteenth-century London, William Farr, a doctor who served as the assistant commissioner for the 1851 city census, asserted that cholera was transmitted by bad air and, in London, specifically by a noxious concentration of miasmata (a non-living entity of organic origin) found along the banks of the Thames (at that time a heavily polluted industrial river). During this era there was no understanding that a single disease could produce multiple symptoms, and thus the diarrhea caused by a cholera infection was seen as a totally different disease from the cholera itself (and not, as it was found to be many decades later, an adaptive strategy that creates an intestinal alkalinity favorable to Vibrio cholerae, the immediate causative agent of cholera). When a major cholera epidemic again broke out in London, in 1854, Farr was appointed by the General Board of Health to the Committee for Scientific Enquiries in Relation to the Cholera Epidemic. Although not as severe as the epidemic of 1849, the 1854 epidemic—during which about 11,000 Londoners succumbed (Winterton, 1980)—was especially devastating in the Broad Street area of the Soho district, where the death toll reached three times the rate in London as a whole.

Snow on Broad Street In addition to being the site of numerous cowsheds, animal slaughterhouses, grease-boiling pots, overcrowded working-class dwellings, and decaying sewers, Soho was home to the now infamous Broad Street pump. John Snow, a physician who had initially gained fame in 1846 by successfully administering the anesthesia chloroform to Queen Victoria during the births of Prince Leopold and Princess Beatrice, claimed that this public water station was the source of the local outbreak and that some kind of living entity in the water, an unseen germ of some sort spread by fecal contamination, was the cause. Snow was convinced the pump was a primary source of infection because the surrounding area was so hard hit during the outbreak. Between August 31 and September 10, over 500 people who lived on or near Broad Street (now renamed Broadwick Street) died of cholera (and ultimately 616 people in Soho were victims of the epidemic). People were fleeing the neighborhood in terror. Snow lived nearby, and he began interviewing the family members of those who had died, thereby inventing field epidemiology in the process. Using addresses that Farr had provided (despite his disagreement with Snow’s perspective on disease causation), it was not long before Snow realized that families who drew their water from the Broad Street pump were the hardest hit and that most of the deaths were among people who lived only a short distance from the pump. He also found that not one of the seventy workers at the nearby Broad Street brewery had gotten sick; these workers were given free beer everyday and consequently never drank water from the pump.

This sociogeographical patterning of disease cases, Snow concluded, could not be explained by miasma theory. To prove his case he even tried examining samples of water from the pump under a microscope, although not one powerful enough for him to see the microbes they contained. Nonetheless he was convinced by his other findings that the germs were there and the cause of the illness and death occurring around him. He consequently self-published a report for distribution to fellow physicians and friends, followed by an essay published in the London Medical Gazette (Summers, 1989). Meanwhile, William Budd, in Bristol, England, who would later gain medical fame by demonstrating that typhoid fever was a waterborne pathogenic disease, had reached a conclusion somewhat similar to Snow’s and published his view in a book a month after Snow’s essay appeared. The difference was that Budd thought the agent of cholera was a fungus, which he and a group of fellow physicians believed they had observed in the stools of cholera patients, a view that was soon discredited.

Contested Understandings The initial response of health officials to Snow’s assertion is reflected in the tone of the summary of it developed by John Simon, a physician who served as the head medical officer of London at the time: “This doctrine is, that cholera propagates itself by a ‘morbid matter’ which, passing from one patient in his evacuations, is accidentally swallowed by other persons as a pollution of food or water; that an increase of the swallowed germ of the disease takes place in the interior of the stomach and bowels, giving rise to the essential actions of cholera, as at first a local derangement; and that the morbid matter of cholera having the property of reproducing its own kind must necessarily have some sort of structure, most likely that of a cell” (quoted in Frerichs, 2001). Although Simon plainly understood Snow’s theory, lacking direct evidence of the cell in question he found the argument, so to speak, hard to swallow, and rejected the relevance of germ theory to the cholera epidemic.

Similarly, despite Snow’s national stature, the Committee for Scientific Enquiries, under Farr’s influence, eventually concluded that “[a]fter careful inquiry, we see no reason to adopt [the belief that the Broad Street pump was to blame for the outbreak]. We do not feel it established that the water was contaminated in the manner alleged [by Snow]; nor is there before us any sufficient evidence to show whether inhabitants of that district, drinking from that well, suffered in proportion more than other inhabitants of the district who drank from other sources” (Eyler, 1979, p. 118).

Instead, cleaving to miasma theory, the committee concluded that “on the whole evidence, it seems impossible to doubt that the influences, which determine in mass the geographical distribution of cholera in London, belong less to the water than to the air.” Indeed, the committee went so far as to scold those who followed Snow in accepting the germ theory of disease: “Many of the public believe that everything we eat and drink teems with life, and that even our bodies abound with minute living and parasitic productions. This is a vulgar error and the notion is as disgusting as it is erroneous” (quoted in Winterton, 1980, p. 17).

Another well-known proponent of the miasmatic theory at the time (although like others working in medicine she later embraced germ theory) was Florence Nightingale, who had gained an international reputation as a devoted nurse during the Crimean War (no mean accomplishment given the opposition to female nurses caring for wounded male soldiers). Because of her belief in miasma theory (and her statistical calculations showing that seven times as many British soldiers died from diseases contracted in the hospital as died from wounds received on the battlefield), she campaigned for the reform of hospitals, insisting that they be regularly cleaned and scoured until sanitary and fresh smelling. During the 1854 cholera epidemic, while serving as superintendent at the Institute for the Care of Sick Gentlewomen, in Upper Harley Street, London, Nightingale also volunteered at Middlesex Hospital, which received many of the victims of the epidemic. Of the 278 cases of cholera treated at the hospital, 123 died—a fatality rate of 53 percent—including one of the hospital’s nurses (Johnson, 2006). Yet to Nightingale’s mind’s eye what was occurring was not the transmission of living, disease-causing microorganisms but rather the emergence of impurities from foul environments. This view also led her to write about her experience with another disease (in a footnote in the pamphlet “Notes on Nursing for the Labouring Classes”), “I have seen with my eyes and smelt with my nose smallpox growing up in first specimens, whether in closed rooms, or in overcrowded wards, where it could not by any possibility have been ‘caught’ but must have begun” (quoted in Penner, 2004, p. 92).

Ending the Epidemic Although the Committee for Scientific Enquiries was later to reach its conclusion that the cause of the cholera epidemic was bad air, when the members of the London Board of Governors heard Snow’s argument, they ordered the closing of the Broad Street pump, and the epidemic soon faded away. Consequently, although no one in London had seen the germ involved in the development of cholera, the 1854 epidemic ultimately gave considerable impetus to the rise to dominance of germ theory within biomedicine. Ironically, Italian biologist Filippo Pacini had already identified the cholera bacterium and had published a scientific paper on his discovery (“Microscopical Observations and Pathological Deductions on Cholera”) through the Paris Academy of Sciences. Using a microscope he had purchased with his limited savings while still a medical student, Pacini conducted histological examination of the intestinal tissues of individuals who had died of cholera in Florence and identified a comma-shaped bacillus that he named Vibrio. Unfortunately, as sometimes happens in science with findings that are ahead of their time, Pacini’s paper was ignored for thirty years, and it is unlikely that Snow had any awareness of it. (Pacini was finally credited with his discovery, eighty-two years after his death, when the International Committee on Nomenclature adopted Vibrio cholerae Pacini as the official name of the microorganism that is the proximal cause of cholera.)

The Rise of Germ Theory

Despite their considerable contributions, neither Snow nor Pacini was in fact the first to propose a germ theory of disease. Almost two thousand years earlier, Marcus Varro (116-127 B.C.), the architect whom Julius Caesar had assigned to the task of building a great public library in ancient Rome (a project that went unrealized because of Caesar’s assassination), had warned those looking to select hygienic locations for buildings to avoid areas near swamps, because “in swampy places minute creatures live that cannot be discerned with the eye and they enter the body through the mouth and nostrils and cause serious disease” (quoted in Amici, 2001, p. 4). How Varro, lacking the technology to identify them, came to believe in the existence of disease-causing microbes is not clear. The microscope was not invented until the late 1600s, although magnifying glasses and the use of emeralds for magnification purposes are mentioned in Naturalis Historia, written by Pliny the Elder, a Roman naturalist and philosopher who lived during the first century A.D. What is known is that Varro’s recognition had little impact on the medical perspective of his day or subsequently and is of interest today primarily as an intriguing footnote in the history of disease understanding.

During the sixteenth century, having observed epidemics of bubonic plague, typhus, and syphilis (and having written a 1,300-verse poem in Latin hexameters focused on a fictional shepherd named Syphilus, the...

Table of contents

• Title Page
• Copyright Page
• Dedication
• PREFACE
• THE AUTHOR
• Acknowledgements
• PART 1 - INTRODUCING KEY CONCEPTS IN SYNDEMICS
• PART 2 - SYNDEMIC CASES
• PART 3 - SOCIETY, HISTORY, AND THE ENVIRONMENT
• PART 4 - APPLICATIONS OF THE SYNDEMIC PERSPECTIVE
• GLOSSARY
• REFERENCES
• INDEX