Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations

Abstract

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.

Figure 1. Model for syndemic approaches to health

(A) Example: depression contributes to pro-inflammatory responses and reduces glucose tolerance. Conversely, inflammatory cytokines associated with diabetes contribute to depression. Treatment of a depressed patient using an atypical antipsychotic adjuvant could contribute to metabolic syndrome, increasing the risk of diabetes. (B) Example: a patient might not perceive diabetes and depression as separate conditions. Instead, the patient focuses on functional limitations such as fatigue and poor concentration. (C) Example: patients diagnosed with diabetes could be provided with health promotion interventions to reduce risk of depression. Patients with both conditions could be enrolled in a collaborative care treatment programme. Social policies should address common risk factors for diabetes and depression (eg, diet and exercise constraints, financial insecurity, interpersonal violence, and social cohesion).