Nicola Bulled

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.

Syringe-Mediated Syndemics

One consequence of the global HIV/AIDS pandemic has been the emergence of a broad awareness of the potential role of syringes in the transmission of infectious diseases. In addition to HIV/AIDS, the use of unsterile syringes by multiple persons has been linked to the spread of Hepatitis B, Hepatitis C, Leishmaniasis, malaria and various other infections. The purpose of this paper is to extend awareness of the grave risks of multiperson syringe use by examining the role of this behavior in the development of infectious disease syndemics. The term syndemics refers to the clustering, often due to noxious social conditions, of two or more diseases in a population resulting in adverse disease synergies that impact human life and well-being. The contemporary appearance and spread of identified syringe-mediated syndemics, and the potential for the emergence of future syringe-mediated syndemics, both of which are reviewed in this paper, underline the importance of public health measures designed to limit syringe-related disease transmission.

The syndemics of childhood diarrhoea: A biosocial perspective on efforts to combat global inequities in diarrhoea-related morbidity and mortality

Diarrhoea remains the second leading cause of death in children under 5 years. Moreover, morbidity as a result of diarrhoea is high particularly in marginalised communities. Frequent bouts of diarrhoea have deleterious and irreversible effects on physical and cognitive development. Children are especially vulnerable given their inability to mount an active immune response to pathogen exposure. Biological limitations are exacerbated by the long-term effects of poverty, including reduced nutrition, poor hygiene and deprived home environments. Drawing from available literature, this paper uses syndemic theory to explore the role of adverse biosocial interactions in increasing the total disease burden of enteric infections in low-resources populations and assesses the limitations of recent global calls to action. The syndemic perspective describes situations in which adverse social conditions, including inequality, poverty and other forms of political and economic oppression, play a critical role in facilitating disease–disease interactions. Given the complex micro- and macro-nature of childhood diarrhoea, including interactions between pathogens, disease conditions and social environments, the syndemic perspective offers a way forward. While rarely the focus of health interventions, technologically advanced biomedical strategies are likely to be more effective if coupled with interventions that address the social conditions of disparity.

Hesitance towards voluntary medical male circumcision in Lesotho: Reconfiguring global health governance

Drawing on work examining HIV prevention initiatives in Lesotho, this paper considers the hesitation of national state actors towards the new strategy for HIV prevention – voluntary medical male circumcision (VMMC). Lesotho offers a representative case study on global health governance, given the countrys high HIV burden and heavy dependence on foreign donor nations to implement local HIV prevention initiatives. In this paper, I use the case of VMMC opposition in Lesotho to examine how the new era of ‘partnerships’ has shifted the architecture of contemporary global health, specifically considering how global agreements are translated or negotiated into local practice. I argue that Lesothos domestic policy-makers, in employing national statistics to assess if VMMC is an effective approach to addressing the local epidemic, are asserting a claim of expertise. In doing so, they challenge the traditional structures of global health politics, which have largely been managed by experts and funders from and in the global North. I explore the development of global VMMC policy, what drives Lesothos resistance to comply, and consider the impact renegotiation efforts may have on future global health architecture.

New lives for old: modernity, biomedicine, traditional culture and HIV prevention in Lesotho

Traditional male circumcision practices have been strongly discouraged by HIV prevention campaigns in Lesotho. Traditional circumcision rituals are perceived as a possible transmission route for HIV because of the reuse of unsterilized cutting instruments. While individuals living in urban areas and the lowlands have increasingly considered traditional circumcision a practice of the past, foregoing the procedure all together, those dwelling in rural areas continue to consider the practice vital in the construction of male national identity. Initially, the national government voiced strong concern over the publicizing of medical male circumcision (MMC) – conducted by surgeons in sterile clinics. There have been claims that male circumcision (either traditional or MMC) does not have the same level of protective benefit against HIV in Lesotho that research suggests it has in other countries in the region. This article critically examines the development of government responses to international expectations o...

Assessing the environmental context of hand washing among school children in Limpopo, South Africa

ABSTRACT Despite its simplicity and efficacy, the promotion of hand washing for disease prevention remains a challenge, particularly in resource-limited settings. This article reports on a quasi-experimental school-based study that aimed to improve habitual hand washing. Significant increases in hand washing occurred following improvements in hygiene and sanitation facilities (School A: t = 13.86, p = 0.0052). Smaller increases in hand washing occurred following education (School A: t = 2.63; p = 0.012; School B, no infrastructure improvements: t = 1.66, p = 0.239). Health policy and programming need to pay greater attention to the interplay of the structural, social and individual dimensions of unique contextual environments that influence habitual behaviours.

Ectoparasitic Syndemics: Polymicrobial Tick‐borne Disease Interactions in a Changing Anthropogenic Landscape

Based on an assessment of the available research, this article uses syndemic theory to suggest the role of adverse bio-social interactions in increasing the total disease burden of tick-borne infections in local populations. Given the worldwide distribution of ticks, capacity for coinfection, the anthropogenic role in environmental changes that facilitate tick dissemination and contact, evidence of syndemic interaction in tick-borne diseases, and growing impact of ticks on global health, tick-borne syndemics reveal fundamental ways in which human beings are not simply agents of environmental change but objects of that change as well.

Conceptualizing Biopolitics: Citizen-State Interactions in the Securing of Water Services in South Africa

Despite constitutional obligations to provide clean water to all citizens in South Africa, access to water and related services remains highly contested. The discord between constitutional promises and lived realities of water access, particularly through national infrastructure, provides a platform on which to examine Foucauldian notions of biopolitics, the control of populations through technologies of governing. Drawing on the situations of residents in the rural Vhembe district in the north eastern corner of the country, I examine how individuals conceptualize the relationship that exists between citizen and state and the responsibilities of each in post-Apartheid South Africa as it relates to water access. In addition, I describe strategies employed throughout South Africa to voice rights to water and how these approaches are perceived. Finally, I consider how the three primary forms of ‘water citizenship’—citizen, agent, and subject—influence the current and future health of vulnerable residents.

Making voluntary medical male circumcision a viable HIV prevention strategy in high-prevalence countries by engaging the traditional sector

Voluntary medical male circumcision (VMMC) has been rapidly accepted by global HIV policy and donor institutions as a highly valuable HIV prevention strategy given its cost-effectiveness, limited interactions with a health facility and projected long-lasting benefits. Many southern African countries have incorporated VMMC into their national HIV prevention strategies. However, intensive VMMC promotion programs have met with limited success to date and many HIV researchers have voiced concerns. This commentary discusses reasons behind the less-than-desired public demand and suggests how inclusion of the traditional sector – traditional leaders, healers, and circumcisers – with their local knowledge, cultural expertise and social capital, particularly in the realm of social meanings ascribed to male circumcision (MC), may improve the uptake of this HIV prevention strategy. We offer Lesotho and Swaziland as case studies of the integration of universal VMMC policies; these are countries with a shared HIV burden, yet contrasting contemporary sociocultural practices of MC. The similar hesitant responses expressed by these two countries towards VMMC remind us that the incorporation of any new or revised and revitalized public health strategy must be considered within unique historical, political, economic, and sociocultural contexts.

Wine Tourism Development in Northern Greece: Evidence From Ktima Gerovassiliou

In an effort to expand the wine tourism industry in Greece, wine producers have formed regional associations, such as the “Wine Producers Association of the Northern Greece Vineyard,” established in 1993. Efforts of this, and similar organizations, involve networking with small-scale wineries, travel agencies, hotels, restaurants, and other local merchants to promote regional wineries, as well as establishing wine tourist routes. Significant work has been conducted investigating consumer motivations and market segmentation in wine tourism, locally and internationally. Informed by this work, wineries can modify the programs offered in order to attract certain market segments. However, examinations of the relationships between the three primary stakeholders in wine tourism—consumers, wine producers, and the tourism agents who promote the programs offered by the wineries—remain limited. This paper explores the interconnections between winemakers, individuals and organizations involved in wine tourism, and consumers to better understand how to improve agritourism in small-scale wineries. In particular, we evaluate the alignment of the winery’s tourism programs, the infrastructure and efforts of established local tourist agency networks, and the motivations of potential domestic consumers.