Addressing Health Disparities From a Syndemic Perspective

As we enter the second year of the COVID-19 pandemic, there is much hope about the eventual containment of the virus, leading to some form of a new normalcy. Multiple COVID-19 vaccines have proven to be effective, and the vaccination of individuals in the United States has reached several million per day, with an ever-growing percentage of the population having been vaccinated. However, there are stark reminders of the continued disparities that have been highlighted by the COVID-19 pandemic, with different levels of vaccine accessibility across states and communities. In addition, multiple countries have not begun any vaccination implementation. Case and death rates continue to be unevenly distributed, with higher death rates in minority populations, particularly African American and Latinx individuals. This pandemic has raised to a higher level of awareness the ongoing and multiple forms of disparity associated with health and illness. For oncology nurses and scientists, how do we look to the issues so starkly presented by the pandemic and raise our awareness that the issues are not specific to COVID-19? The commonalities faced by individuals and families who face choices related to health attainment in the context of the COVID-19 pandemic have relevance for cancer prevention, treatment, and survivorship. Can we use the heightened awareness to structural issues brought to the forefront by the pandemic to better understand the ongoing structural challenges that affect health in our country and across the world, adding a perspective about the societal, social, and political contributions to health and illness?

Syndemic (synergy of epidemic) theory, developed by medical anthropologists in the early 2000s, provides a framework to examine mutually enhancing diseases/health issues under conditions of social inequality and inequity. Multiple, intertwined health problems occurring in a population simultaneously experiencing poor physical and social conditions comprise a syndemic (Singer, 2009). Syndemic theory has been used to address interacting aspects of diseases and other conditions that may seem to be biomedical but have important aspects of facilitation or protection based on structural phenomena (Himmelgreen et al., 2020). Syndemics-based focus goes beyond common biomedical concepts of health and illness and extends to the health consequences of identifiable disease interactions and the social, environmental, or economic factors that promote such interaction and worsen disease or present barriers to prevention and treatment (Singer et al., 2017). Syndemics focuses on the social, psychological, and biological reasons that diseases cluster, the ways comorbid diseases affect each other, how important these interactions can be to the health burden within the populations, the pathways of disease interaction, and the way in which health is affected by the physical and social environments (Singer et al., 2017). Central to this concept is the nexus of adverse interactions of disease and disease risk that social and environmental factors (including corporate exploitation, rapid economic transitions, limited healthcare access, poverty, social trauma and structural violence, human rights violations, wars, and environmental threats, such as global warming and environmental degradation) adversely affect. One of the major principles of syndemic theory is a refocus from the individual or the health problem from an acontextual, singular perspective to an embedded perspective that includes the social, societal, and political components of health and illness. The social context (inequality and injustice) that provides an environment in which overall disease burden can multiply affects not only infectious disease during pandemics, but also noncommunicable conditions across the health and disease continuum (Vega, 2019). According to Rutter et al. (2017), “instead of asking whether an intervention works to fix a problem, researchers should aim to identify if and how it contributes to reshaping a system in favorable ways” (p. 2,602). In this way, syndemic theory considers multiple levels of impact, including the supra-individual, social, or structural determinants, or area- or place-based factors, in shaping the background of the health issue.

What are the implications for oncology nursing research from a syndemics framework? There must be a heightened appreciation of the interrelated complexities that promote health across communities and to address the scope and context of health and illness, even if we do not yet know how to successfully promote positive changes in the context of structural barriers. Although our nursing metaparadigm includes the aspect of environment, most of the focus has been on environmental aspects as externalities and not essentialities. For those of us educated to focus less on social and political issues in health care and more on individual-level patient care and research outcomes, appreciating the effects of intersectional elements of health will involve an openness to changing not only our research focus, but also our methodologies to understand and influence these structural dimensions. For oncology nurse scientists, we are moved to understand traditional oncology treatment within a COVID-19 perspective; now, our challenge is moving forward with these understandings to affect disparities in cancer prevention, treatment, and outcomes. Moving forward with old models postpandemic will not be sufficient.

About the Author(s)

Debra Lyon, RN, PhD, FNP-BC, FAAN, is the executive associate dean and Kirbo Endowed Chair in the College of Nursing at the University of Florida in Gainesville. Lyon can be reached at ONFEditor@ons.org.