Merrill Singer

Aids and the health crisis of the U.S. urban poor; the perspective of critical medical anthropology

The social identity of HIV/AIDS in the U.S. has been shaped, for the most part, by two factors, the prevailing configuration of social relations across class, racial, gender, and sexual orientation, on the one hand, and the prevailing array of public health, especially epidemiological, categories of disease transmission, on the other. Focusing on the AIDS epidemic among inner city people of color, this paper challenges the distortions wrought in our understanding from both of these factors and instead develops an alternative perspective for AIDS research among medical anthropologists and health social scientists generally.

Syndemics, sex and the city: Understanding sexually transmitted diseases in social and cultural context

Abstract This paper employs syndemics theory to explain high rates of sexually transmitted disease among inner city African American and Puerto Rican heterosexual young adults in Hartford, CT, USA. Syndemic theory helps to elucidate the tendency for multiple co-terminus and interacting epidemics to develop under conditions of health and social disparity. Based on enhanced focus group and in-depth interview data, the paper argues that respondents employed a cultural logic of risk assessment which put them at high risk for STD infection. This cultural logic was shaped by their experiences of growing up in the inner city which included: coming of age in an impoverished family, living in a broken home, experiencing domestic violence, limited expectations of the future, limited exposure to positive role models, lack of expectation of the dependency of others, and fear of intimacy.

Rapid Assessment of the HIV/AIDS Crisis in Racial and Ethnic Minority Communities: An Approach for Timely Community Interventions

OBJECTIVES The US Department of Health and Human Services, in collaboration with the Congressional Black Caucus, created a new initiative to address the disproportionate ongoing HIV/AIDS crisis in racial/ethnic minority populations. METHODS This initiative included deploying technical assistance teams through the Office of HIV/AIDS Policy. The teams introduced rapid assessment and response methodologies and trained minority communities in their use. RESULTS The first 3 eligible cities (Detroit, Miami, and Philadelphia) focused assessments in small geographic areas, using multiple methodologies to obtain data. CONCLUSIONS Data from the first 3 eligible cities provided critical information about changing the dynamics of the HIV/AIDS epidemic at the local level, including program and policy changes and infrastructure redeployment targeted at the most serious social and environmental conditions.

A Methodological Model for Rapid Assessment, Response, and Evaluation: The RARE Program in Public Health

Rapid assessment projects are expanding in the arenas of public health policy, planning, and program development in both developing and developed nations. This article reviews the methodological advances that have changed rapid assessment from a primarily “quick and dirty” approach for data collection into a public health tool for time-sensitive development of changes in intervention strategies, community-based organizational structure, program evaluation, and policy decisions. The methodological design of the Rapid Assessment, Response, and Evaluation Project, adopted by the Office of HIV/AIDS Policy (U.S. Department of Health and Human Services) in 1999, is presented as a model for using revised rapid assessment approaches within the context of public health policy development.

Reinventing medical anthropology: toward a critical realignment.

Responding to the narrow focus, medicalization, and inattention to political-economy within conventional medical anthropology, a growing number of researchers are participating in a significant restructuring of the subdiscipline. The paper examines several shortcomings of contemporary medical anthropology and, building on the work of the emergent critical trend, identifies key areas of theory and practice for furthering the critical realignment of medical anthropology.

A comparison of the nutritional status and food security of drug-using and non-drug-using Hispanic women in Hartford, Connecticut

This study compared food insecurity, nutritional status (as measured through anthropometry and dietary intake), and food preparation patterns of low-income Puerto Rican female out-of-treatment drug users with that of low-income Puerto Rican women who reported no drug use. A convenience sample of 41 drug users was compared with 41 age-matched non-drug-users from inner-city Hartford, Connecticut. A culturally appropriate food frequency questionnaire was administered and anthropometric measurements were taken. The findings suggest a high degree of poverty among all study participants, but in particular among drug users. Drug users were more likely than the controls to be food insecure (P < 0.05) and to be exposed to increasingly severe food sufficiency problems. The daily frequency of consumption of vegetables was lower (P = 0.03) for drug users than non-drug-users. Conversely, the frequency of consumption for sweets/desserts was significantly higher for drug users than the controls (P = 0.0001). Drug users, who were classified as food insecure were less likely to consume vegetables (P = 0.004) and fish (P = 0.03) than were controls who were food insecure. When comparing drug users with controls, the former group reported consuming fewer meals during a usual week than the latter group (P < 0.0001). Drug users were more likely to fry foods (P = 0.02) while the controls were more likely to bake (P = 0.005), boil (P = 0.02), and steam (P = 0.002) foods. All anthropometric measurements, except for height, were significantly lower for drug users. The results show that drug users generally maintain poorer nutritional status than non-drug-users. Nutrition interventions as part of drug treatment are needed.

The coming of age of critical medical anthropology

This paper reviews the development over the last 15 years of a broadening critical trend in the field of medical anthropology by: (1) examining shortcomings of conventional medical anthropology that led to interest in critical alternatives; (2) examining historical and occupational factors that tend to conservatize the subdiscipline; (3) reviewing the body of literature produced thus far by its adherents; and (4) suggesting directions for future work.

Toward a political-economy of alcoholism: the missing link in the anthropology of drinking.

This paper addresses a shortcoming in the existing anthropological and related social science literature on alcohol use and abuse, namely the general inattention to global political-economic forces that have in the past and continue to reshape social relations and drinking practices cross-culturally. Following a critical review of the dominant approaches adopted in the varying explanations of heavy drinking and alcoholism, several alternative concepts are presented and developed in order to lay the ground for the emergence of a political-economy of alcoholism. The paper urges transcendence of the existing narrow boundaries of inquiry and perspective characteristic of most anthropological study of drinking and drinking problems.

Syndemics and the biosocial conception of health

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

I love you ... and heroin: care and collusion among drug-using couples

BackgroundRomantic partnerships between drug-using couples, when they are recognized at all, tend to be viewed as dysfunctional, unstable, utilitarian, and often violent. This study presents a more nuanced portrayal by describing the interpersonal dynamics of 10 heroin and cocaine-using couples from Hartford, Connecticut.ResultsThese couples cared for each other similarly to the ways that non-drug-using couples care for their intimate partners. However, most also cared by helping each other avoid the symptoms of drug withdrawal. They did this by colluding with each other to procure and use drugs. Care and collusion in procuring and using drugs involved meanings and social practices that were constituted and reproduced by both partners in an interpersonal dynamic that was often overtly gendered. These gendered dynamics could be fluid and changed over time in response to altered circumstances and/or individual agency. They also were shaped by and interacted with long-standing historical, economic and socio-cultural forces including the persistent economic inequality, racism and other forms of structural violence endemic in the inner-city Hartford neighborhoods where these couples resided. As a result, these relationships offered both risk and protection from HIV, HCV and other health threats (e.g. arrest and violence).ConclusionA more complex and nuanced understanding of drug-using couples can be tapped for its potential in shaping prevention and intervention efforts. For example, drug treatment providers need to establish policies which recognize the existence and importance of interpersonal dynamics between drug users, and work with them to coordinate detoxification and treatment for both partners, whenever possible, as well as provide additional couples-oriented services in an integrated and comprehensive drug treatment system.