24 therefore recognising syndemics requires that

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24 Therefore, recognising syndemics requires that clinicians and epidemiologists incorporate the effect of co-occuring conditions, including social problems, in assessing adverse health outcomes as well as in establishing best treatment practices ( figure ). 1. Download high-res image (198KB) 2. Download full-size image Figure. Model of a syndemic Syndemics are not limited to infectious diseases. The VIDDA syndemic is an example of how non-communicable diseases and health conditions cluster and interact. This syndemic unites violence, immigration, depression, type 2 diabetes , and abuse as mutually exacerbating factors in the health of Mexican immigrant women in the USA. 8 Depression is a crucial element in other syndemics as well. Thus the WHO World Health Survey 25 of four chronic diseases (angina, arthritis, asthma, and diabetes) in a sample of almost 250 000 adults from 60 countries showed that comorbidity with depression incrementally worsens health beyond what was found with any of the
chronic diseases alone, or with any combination of the four chronic diseases without depression. Syndemics, in short, occur across the disease spectrum and often involve adverse interactions among diverse psychiatric and biological disorders. Syndemic pathways A core concern of syndemics research is the investigation of the specific pathways through which disease and other health conditions interact in the body and within populations to allow multiplication of adverse health effects. Domains of social– psychological, psychological–biological, and social–biological interaction are as fundamental to syndemics as biological interactions are. Syndemics are not characterised merely by co-occurring conditions, but rather exemplify the nature of the changes and exchanges that exacerbate the severity or progression of disease. HIV/AIDS serves as an exemplary syndemic case precisely because most of these interactive pathways involve varying socioenvironmental conditions and biological, social, and structural factors that create a distinct pattern of HIV/AIDS risk. Such pathways include pathogen–pathogen interactions in which multiple biological factors intersect and interact to increase disease susceptibility or level of affliction, as well as biosocial pathways in which social and structural factors interact with biological factors to produce a greater level of disease risk and higher health burden ( panel 2 ). 7 Panel 2 Types of syndemic interaction among diseases Enhanced contagiousness Accelerated virulence Alterations of the physical body Alterations of the emotions Gene reassortment Iatrogenic factors
A common observation in cases of comorbidity is for one disease to promote or enhance the contagiousness of another disease by facilitating its access through body defences to susceptible tissues. This type of assistance is seen in the bidirectional interaction between HIV and chlamydia , leading to genital ulcerative disease.

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