Medicine:Syndemic

A syndemic or synergistic epidemic is the aggregation of two or more concurrent or sequential epidemics or disease clusters in a population with biological interactions, which exacerbate the prognosis and burden of disease. The term was developed by Merrill Singer in the mid-1990s. Syndemics develop under health disparity, caused by poverty, stress, or structural violence and are studied by epidemiologists and medical anthropologists concerned with public health, community health and the effects of social conditions on health.

The syndemic approach departs from the biomedical approach to diseases to diagnostically isolate, study, and treat diseases as distinct entities separate from other diseases and independent of social contexts.

Definition

A syndemic is a synergistic epidemic. The term was developed by Merrill Singer in the mid-1990s, culminating in a 2009 textbook. Disease concentration, disease interaction, and their underlying social forces are the core concepts. Disease co-occurrence, with or without interactions, is known as comorbidity and coinfection. The difference between "comorbid" and "syndemic" is per Mustanski et al. (2008:40) "comorbidity research tends to focus on the nosological issues of boundaries and overlap of diagnoses, while syndemic research focuses on communities experiencing co-occurring epidemics that additively increase negative health consequences." It is possible for two afflictions to be comorbid, but not syndemic i.e., the disorders are not epidemic in the studied population, or their co-occurrence is not accompanied by worsened health. Two or more diseases can be comorbid without interactions, or interaction occurs but it is beneficial, not deleterious. Syndemic theory seeks to draw attention to and provide a framework for the analysis of adverse disease interactions, including their causes and consequences for human life and well-being.

Types of disease interaction

Diseases regularly interact and this interaction influences disease course, expression, severity, transmission, and diffusion. Interaction among diseases may be both indirect (changes caused by one disease that facilitate another through an intermediary) and direct (diseases act in direct tandem).

• One disease can assist the physical transmission of the microbe causing another disease, for example, genital-tract ulceration caused by syphilis allowing sexual transmission of HIV.
• One disease may enhance the virulence of another, as for example, herpes simplex virus co-infection exacerbates HIV infection with progression to AIDS, periodontal bacteria may enhance the virulence of herpesvirus, HIV-infected individuals are more susceptible to tuberculosis; As of 2011, the cause was not fully understood.
• Changes in biochemistry or damage to organ systems, as for example diabetes weakening the immune system, promotes the progression of another disease, SARS.
• A coinfection may open up multiple syndemic pathways. Lethal synergism between influenza virus and pneumococcus, causes excess mortality from secondary bacterial pneumonia during influenza epidemics. Influenza virus alters the lungs in ways that increase the adherence, invasion and induction of disease by pneumococcus, alters the immune response with weakened ability to clear pneumococcus or, alternately amplifying the inflammatory cascade.
• Direct interaction of diseases occurs in the case of genetic recombination among different pathogens, for instance between Avian sarcoma leukosis virus and Marek's disease virus (MDV) in domestic fowl. Both cancer-causing viruses are known to infect the same poultry flock, the same chicken, and, even the same anatomic cell. In coinfected cells, the retroviral DNA of the avian leukosis virus can integrate into the MDV genome, producing altered biological properties compared to those of the parental MDV. The frequency of gene reassortment among human pathogens is less clear than it is the among plant or animal species but of concern as animal diseases adapt to human hosts and as man new diseases comes into contact.
• When one disease diminishes or eradicates another it is a counter-syndemic disease interaction.
• The linkage also may not be clear, despite obvious syndemic interactions among diseases, as for example in type 2 diabetes mellitus and hepatitis C virus infection.

Iatrogenic

The term iatrogenesis means "brought forth by a healer" and refers to adverse effects on health caused by medical treatment. This is possible if medical treatment or medical research creates conditions that increase the likelihood that two or more diseases come together in a population. For example, if gene splicing unites two pathogenic agents and the resulting novel organism infects a population. One study suggests the possibility of iatriogenic syndemics. During a randomized, double-blind clinical trial testing the efficacy of the prototype HIV vaccine called V520 there appeared to be an increased risk for HIV infection among the vaccinated participants. Notably, participants immune to the common cold virus adenovirus type 5 had a higher risk of HIV infection. The vaccine was created using a replication-defective version of Ad5 as a carrier, or delivery vector, for three synthetically produced HIV genes. On November 6, 2007, Merck & Co. announced that research had been stopped suspecting the higher rate of HIV infection among individuals in the vaccinated was because the vaccine lowered defenses against HIV.

Examples

Various syndemics though not always labeled as such have been described in the literature, including the

• SAVA syndemic (substance abuse, violence and AIDS,
• the hookworm, malaria and HIV/AIDS syndemic,
• the Chagas disease, rheumatic heart disease and congestive heart failure syndemic,
• the possible asthma and infectious disease syndemic,
• the malnutrition and depression syndemic,
• the TB, HIV and violence syndemic,
• the whooping cough, influenza, tuberculosis syndemic,
• the HIV and STD syndemic,
• the stress and obesity syndemic,
• the HIV infection, mental health and substance abuse syndemic.
• the built environment, physical inactivity and obesity/diabetes syndemic, which Prince Charles pointed out in January 2006, in a speech at the Enhancing the Healing Environment conference hosted by The Prince's Foundation for the Built Environment and The King's Fund, St James's Palace, London.
• HIV infection and opportunistic microbial infections and viral-caused malignancies like Kaposi's Sarcoma
• periodontitis and herpes virus: bacteria of several different species (e.g., Porphyromonas gingivalis, Dialister pneumosintes, Prevotella intermedia) that adhere to and reproduce on tooth surfaces under the gum line multiply when bodily defenses are weakened by an HSV infection of the periodontium.
• HIV being transiently suppressed during an acute measles infection. Several potential mechanisms could be responsible. Measles virus infection causes lymphopenia, a reduction in the number of CD4+ T lymphocytes circulating in the blood. The low point occurs just prior to the onset of the characteristic skin rash. Within a month of this nadir, the number of lymphocytes return to normal levels. The drop in HIV virus levels may be due to a lack of target CD4+ T cells in which they replicate, or measles virus may stimulate the production of proteins suppressing HIV replication, including the β-chemokines, CD8+ cell noncytotoxic anti-HIV response, and the cytokines IL-10 and IL-16. median plasma levels of RANTES, a chemokine that attracts immune system components like eosinophils, monocytes, and lymphocytes were higher in HIV-infected children with measles than in those without measles(Moss and co-workers).
• HIV suppression in tsutsugamuchi disease or scrub typhus, a mite-borne infection in Asia and Australia, but how this occurs is unclear.

19th century Native American

Contact between Native Americans and Europeans during the Columbian Exchange led to lethal syndemics within the Native American population due to diseases introduced which the Native Americans had not encountered before and had not built-up immunity to.

An example of a syndemic from the 19th century can be found on the reservations on which Native Americans were confined with the closing of the U.S. frontier. It is estimated that in 1860 there were well over 10 million bison living on the American Plains. By the early 1880s, the last of the great herds of bison upon which Plains Indian peoples like the Sioux were dependent as a food source were gone. At the same time, after the U.S. military's defeat at the Battle of the Little Bighorn in 1876, there was a concerted effort to beat the Sioux into total submission. Thus, in 1872, Secretary of the Interior Columbus Delano stated: "as they become convinced that they can no longer rely upon the supply of game for their support, they will return to the more reliable source of subsistence [i.e., farming]." As a result, they were forced to give up their struggle for an independent existence on their own lands and take up reservation life at the mercy of government authority. Treaties that were signed with the Sioux in 1868 and 1876 stipulated that they would be provided with government annuities and provisions in payment for sections of their land and with the expectation among federal representatives that the Sioux would become farmers on individually held plots of land. The Sioux found themselves confined on a series of small reservations where they were treated as a conquered people. Moreover, the government reneged on its promises, food was insufficient and of low quality. Black Elk, a noted Sioux folk healer, told his biographer: "There was hunger among my people before I went across the big water [to Europe in 1886], because the Wasichus [whites] did not give us all the food they promised in the Black Hills treaty... But it was worse when I came back [1889]. My people looked pitiful… We could not eat lies and there was nothing we could do." Under extremely stressful conditions, with inadequate diets, and as victims of overt racism on the part of the registration agents appointed to oversee Indian reserves, the Sioux confronted infectious disease from contact with whites. knowledge about the epidemiology of the Sioux from this period is limited, James Mooney, an anthropologist and representative of the Bureau of Indian Affairs sent to investigate a possible Sioux rebellion, described the health situation on the reservation in 1896: "In 1888 their cattle had been diminished by disease. In 1889, their crops were a failure ... Thus followed epidemics of measles, grippe [influenza], and whooping cough Pertussis, in rapid succession and with terrible fatal results…" Similarly, the Handbook of American Indians notes, "The least hopeful conditions in this respect prevail among the Dakota [Sioux] and other tribes of the colder northern regions, where pulmonary tuberculosis and scrofula are very common… Other more common diseases, are various forms of, bronchitis ...pneumonia, pleurisy, and measles in the young. Whooping cough is also met with." Indian children were removed to white boarding schools and diagnosed with a wide range of diseases, including tuberculosis, trachoma, measles, smallpox, whooping cough, influenza, and pneumonia.

The Sioux were victims of a syndemic of interacting infectious diseases including the 1889–1890 flu pandemic, inadequate diet, and stressful and extremely disheartening life conditions, including outright brutalization with events like the massacre at Wounded Knee in 1890 and the murder of their leader Sitting Bull. While the official mortality rate on the reservation was between one and two percent, the death rate was probably closer to 10 percent.

Influenza

There were three influenza pandemics during the 20th century that caused widespread illness, mortality, social disruption, and significant economic losses. These occurred in 1918, 1957, and 1968. In each case, mortality rates were determined primarily by five factors: the number of people who became infected, the virulence of the virus causing the pandemic, the speed of global spread, the underlying features and vulnerabilities of the most affected populations, and the effectiveness and timeliness of the prevention and treatment measures that were implemented.

The 1957 pandemic was caused by the Asian influenza virus (known as the H2N2 strain), a novel influenza variety to which humans had not yet developed immunities. The death toll of the 1957 pandemic is estimated to have been around two million globally, with approximately 70,000 deaths in the United States. A little over a decade later, the comparatively mild Hong Kong influenza pandemic erupted due to the spread of a virus strain (H3N2) that genetically was related to the more deadly form seen in 1957. The pandemic was responsible for about one million deaths around the world, almost 34,000 of which were in the United States. In both of these pandemics, death may not have been due only to the primary viral infection, but also to secondary bacterial infections among influenza patients; in short, they were caused by a viral/bacterial syndemic (but see Chatterjee 2007).

The worst of the 20th century influenza pandemics was the 1918 pandemic, where between 20-40 percent of the world’s population became ill between 40-100 million people died. More people died of the so-called Spanish flu (caused by the H1N1 viral strain) pandemic in the single year of 1918 than during all four-years of the Black Death. The pandemic had devastating effects as disease spread along trade and shipping routes and other corridors of human movement until it had circled the globe. InIndia, the mortality rate reached 50 per 1,000 population. Arriving during the closing phase of the World War I, the pandemic impacted mobilized national armies. Half of U.S. soldiers who died in the "Great War," for example, were victims of influenza. It is estimated that almost ¾ of a million Americans died during the pandemic. In part, the death toll during the pandemic was caused by viral pneumonia characterized by extensive bleeding in the lungs resulting in suffocation. Many victims died within 48 hours of the appearance of the first symptom. It was not uncommon for people who appeared to be quite healthy in the morning to have died by sunset. Among those who survived the first several days, however, many died of secondary bacterial pneumonia. It has been argued that countless numbers of those who expired quickly from the disease were co-infected with tuberculosis, which would explain the notable plummet in TB cases after 1918.

Climate change

As a result of the floral changes produced by global warming, an escalation is occurring in global rates of allergies and asthma. Allergic diseases constitute the sixth leading cause of chronic illness in the United States, impacting 17 percent of the population. Asthma affects about 8 percent of the U.S. population, with rising tenndency, especially in low income, ethnic minority neighborhoods in cities. In 1980 asthma affected only about three percent of the U.S. population according to the U.S. CDC. Asthma among children has been increasing at an even faster pace than among adults, with the percentage of children with asthma going up from 3.6 percent in 1980 to 9 percent in 2005. Among ethnic minority populations, like Puerto Ricans the rate of asthma is 125 percent higher than non-Hispanic white people and 80 percent higher than non-Hispanic black people. The asthma prevalence among American Indians, Alaska Natives and black people is 25 percent higher than in white people.

Air pollution

Increases in asthma rates have occurred despite improvements in air quality produced by the passage and enforcement of clean air legislation, such as the U.S. Clean Air Act of 1963 and the Clean Air Act of 1990. existing legislation and regulation have not kept pace with changing climatic conditions and their health consequences. Compounding the problem of air quality is the fact that air-borne pollens have been found to attach themselves to diesel particles from truck or other vehicular exhaust floating in the air, resulting in heightened rates of asthma in areas where busy roads bisect densely populated areas, most notably in poorer inner city areas.

For every elevation of 10 μg/m3 in particulate matter concentration in the air a six percent increase in cardiopulmonary deaths occurs according to research by the American Cancer Society. Exhaust from the burning of diesel fuel is a complex mixture of vapors, gases, and fine particles, including over 40 known pollutants like nitrogen oxide and known or suspected carcinogenic substances such as benzene, arsenic, and formaldehyde. Exposure to diesel exhaust irritates the eyes, nose, throat and lungs, causing coughs, headaches, light headedness and nausea, while causing people with allergies to be more susceptible allergy triggers like dust or pollen. Many particles in disease fuel are so tiny they are able to penetrate deep into the lungs when inhaled. Importantly, diesel fuel particles appear to have even greater immunologic effects in the presence of environmental allergens than they do alone. "This immunologic evidence may help explain the epidemiologic studies indicating that children living along major trucking thoroughfares are at increased risk for asthmatic and allergic symptoms and are more likely to have respiratory dysfunction." according to Robert Pandya and co-workers.

The damaging effects of diesel fuel pollution goes beyond a synergistic role in asthma development. Exposure to a combination of microscopic diesel fuel particles among people with high blood cholesterol (i.e., low-density lipoprotein, LDL or "bad cholesterol") increases the risk for both heart attack and stroke above levels found among those exposed to only one of these health risks. According to André Nel, Chief of Nanomedicine at the David Geffen School of Medicine at UCLA, "When you add one plus one, it normally totals two... But we found that adding diesel particles to cholesterol fats equals three. Their combination creates a dangerous synergy that wreaks cardiovascular havoc far beyond what's caused by the diesel or cholesterol alone." Experimentation revealed that the two mechanisms worked in tandem to stimulate genes that promote cell inflammation, a primary risk for hardening and blockage of blood vessels (atherosclerosis) and, as narrowed arteries collect cholesterol deposits and trigger blood clots, for heart attacks and strokes as well.

Mathematical modelling

A mathematical model is a simplified representation using mathematical language to describe natural, mechanical or social system dynamics. Epidemiological modelers unite several types of information and analytic capacity, including: 1) mathematical equations and computational algorithms; 2) computer technology; 3) epidemiological knowledge about infectious disease dynamics, including information about specific pathogens and disease vectors; and 4) research data on social conditions and human behavior. Mathematical modelling in epidemiology is now being applied to syndemics.

For example, modelling to quantify the syndemic effects of malaria and HIV in sub-Saharan Africa based on research in Kisumu, Kenya researchers found that 5% of HIV infections (or 8,500 cases of HIV since 1980) in Kisumu are the result of the higher HIV infectiousness of malaria-infected HIV patients. Additionally, their model attributed 10% of adult malaria episodes (or almost one million excess malaria infections since 1980) to the greater susceptibility of HIV infected individuals to malaria. Their model also suggests that HIV has contributed to the wider geographic spread of malaria in Africa, a process previously thought to be the consequence primarily of global warming. Modelling offers an enormously useful tool for anticipating future syndemics, including eco-syndemic, based on information about the spread of various diseases across the planet and the consequent co-infections and disease interactions that will result.

PopMod is a longitudinal population tool developed in 2003 that models distinct and possibly interacting diseases. Unlike other life-table population models, PopMod is designed to not assume the statistical independence of the diseases of interest. The PopMod has several intended purposes, including describing the time evolution of population health for standard demographic purposes (such as estimating healthy life expectancy in a population), and providing a standard measure of effectiveness for health interventions and cost-effectiveness analysis. PopMod is used as one of the standard tools of the World Health Organization’s (WHO) CHOICE (Choosing Interventions that are Cost-Effective) program, an initiative designed to provide national health policy makers in the WHO’s 14 epidemiological sub-regions around the world with findings on a range of health intervention costs and effects.

Although in Merrill Singer's conceptual work on syndemics the study of disease interaction is a central issue, most empirically based research studies have not used appropriate statistical models to do so. This problem was highlighted in a 2015 review. The majority (78%) used a statistical model, which provided no information about disease interaction. The methodological and public health consequences of this type of statistical model were further highlighted. While this criticism does not undermine the concept of disease concentration, it highlights a seriously flawed way of syndemics investigations.

Future research

First, there is a need for studies that examine the processes by which syndemics emerge, the specific sets of health and social conditions that foster multiple epidemics in a population and how syndemics function to produce specific kinds of health outcomes in populations.Second, there is a need to better understand processes of interaction between specific diseases with each other and with health-related factors like malnutrition, structural violence, discrimination, stigmatization, and toxic environmental exposure that reflect oppressive social relationships. There is a need to identify all of the ways, directly and indirectly, that diseases can interact and have, as a result, enhanced impact on human health. Third there is a need for the development of an eco-syndemic understanding of the ways in which global warming contributes to the spread of diseases and new disease interactions. There is a need for a better understanding of how public health systems and communities can best respond to and limit the health consequences of syndemics. Systems are needed to monitor the emergence of syndemics and to allow early medical and public health responses to lessen their impact. Systematic ethno-epidemiological surveillance with populations subject to multiple social stressors must be one component of such a monitoring system.

See also

• Endemic
• List of epidemics
• List of human diseases associated with infectious pathogens

Further reading

Books

• Marshall, Mac 2013 Drinking Smoke: The Tobacco Syndemic in Oceania. Honolulu, HI: University of Hawai'i Press.
• Mendenhall, Emily 2012 Syndemic Suffering: Social Distress, Depression, and Diabetes among Mexican Immigrant Women. Left Coast Press, Inc.
• Singer, Merrill 2009 Introduction to Syndemics: A Systems Approach to Public and Community Health. San Francisco, CA: Jossey-Bass.

Articles, chapters

• Akksilp, Somsak, Karnkawinpong, Opart, Wattanaamornkiat, Wanpen, Viriyakitja, Daranee, Monkongdee, Patama, Sitti, Walya, Rienthong, Dhanida, Siraprapasiri, Taweesap, Wells, Charles D., Tappero, Jordan W. and Varmaet, Jay K. 2007 Antiretroviral Therapy during Tuberculosis Treatment and Marked Reduction in Death Rate of HIV-infected Patients, Thailand. Emerging Infectious Diseases 13(7). Available online at: https://www.cdc.gov/EID/content/13/7/1001.htm.
• Alisjahbana B.; van Crevel R.; Sahiratmadja E.; den Heijer M.; Maya A. (2006). "Diabetes mellitus is strongly associated with tuberculosis in Indonesia". International Journal Tuberculosis and Lung Disease 10: 696–700. 
• Andreani Guadalupe; Lodge Robert; Richard Dave; Tremblay Michel (2012). "Mechanisms of Interaction between Protozoanarasites and HIV". Current Opinion in HIV and AIDS 7: 276–282. doi:10.1097/coh.0b013e32835211e9. 
• Bini Edmund; Perumalswami Ponni (2010). "Hepatitis B Virus Infection Among American Patients with Chronic Hepatitis C Virus Infection: Prevalence, Racial/Ethnic Differences, and Viral Interactions". Hepatology 51: 759–766. doi:10.1002/hep.23461. PMID 20140950. 
• Brennan Julia; Kuhns Lisa; Johnson Amy; Belzer Marvin; Wilson Erin; Garofalo Robert (2012). "Syndemic Theory and HIV-Related Risk Among Young Transgender Women: The Role of Multiple Co-Occurring Health Problems and Social Marginalization". American Journal of Public Health 102 (9): 1751–1757. doi:10.2105/ajph.2011.300433. PMID 22873480. 
• Bruce Douglas; Harper Gary; Interventions AIDS (2011). "Operating Without a Safety Net: Gay Male Adolescents and Emerging Adults' Experiences of Marginalization and Migration, and Implications for Theory of Syndemic Production of Health Disparities". Health Education & Behavior 38 (4): 367–378. doi:10.1177/1090198110375911. 
• Brunarski David (2011). "The Increasing Threat of Syndemics and the Role of Chiropractic Care". Dynamic Chiropractic 4 (2): 1. 
• Brunner E.; Chandola T.; Marmot M. (2007). "Prospective Effect of Job Strain on General and Central Obesity in the Whitehall II Study". American Journal of Epidemiology 165: 828–837. doi:10.1093/aje/kwk058. PMID 17244635. 
• Bulled Nicola; Singer Merrill (2011). "Syringe-mediated Syndemics". AIDS and Behavior 15 (7): 1539–1545. doi:10.1007/s10461-009-9631-1. 
• Chatterjee, R. 2007 Portrait of a Killer. Science Magazine 117(2). Available online at: https://www.sciencemag.org/news/2007/01/portrait-killer.
• Chaulk C. Patrick; Kazandjian Vahé (2004). "Moving Beyond Randomized Controlled Trials". American Journal of Public Health 94 (9): 1476. doi:10.2105/ajph.94.9.1476. 
• Cohen Craig; Duerr Ann; Pruithithada Niwat; Rugpao Sungwal; Garcia Patricia; Nelson Kenrad; Hillier Sharon (1995). "Bacterial Vaginosis and HIV Seroprevalence among Female Commercial Sex Workers in Chiang Mai, Thailand". AIDS 9 (9): 1093–1098. doi:10.1097/00002030-199509000-00017. 
• Chu, P., Santos, G.-M., Vu, A., Nieves-Rivera, G., Colfax, J., Grinsdale, S., Huang, S., Phillip, S., Scheer, S. and Aragon, T. 2012 Impact of syndemics on people living with HIV in San Francisco. Presented at the XIX International AIDS Conference, Washington, D.C. (MOACO202 Oral Abstract).
• Conant K.; Kaleeba J. (2013). "Dangerous liaisons: molecular basis for a syndemic relationship between Kaposi's sarcoma and P. falciparum malaria". Frontiers in Microbiology 4: 35. doi:10.3389/fmicb.2013.00035. 
• Correa-Oliveira R.; Golgher D.; Oliveira G.; Carvalho O.; Massara C.; Caldas I.; Colley D.; Gazzinelli G. (2002). "Infection with Schistosoma mansoni correlates with altered immune responses to Ascaris lumbricoides and hookworm". Acta Tropica 83: 123–132. doi:10.1016/s0001-706x(02)00108-0. 
• Cui Yang; Koblin Beryl (2011). "Migration, Neighborhoods, and Networks: Approaches to Understanding How Urban Environmental Conditions Affect Syndemic Adverse Health Outcomes Among Gay, Bisexual and Other Men Who Have Sex With Men". AIDS and Behavior 15 (Suppl 1): S35–S50. doi:10.1007/s10461-011-9902-5. 
• Daftary A (2012). "HIV and tuberculosis: The construction and management of double stigma". Social Science & Medicine 74 (10): 1512–1519. doi:10.1016/j.socscimed.2012.01.027. 
• Daftary A.; Padayatchi N. (2012). "Social constraints to TB/HIV healthcare: Accounts from coinfected patients in South Africa". AIDS Care 24: 1480–1486. doi:10.1080/09540121.2012.672719. 
• Santis De, Joseph Layerla, Dennys Barroso, Susana Gattamorta, Karina Sanchez, Michael, Prado Guillermo (2012). "Predictors of Eating Attitudes and Behaviors Among Gay Hispanic Men". Archives of Nursing 26 (2): 111–126. doi:10.1016/j.apnu.2011.06.003. 
• Diedrich C.; Flynn J. (2011). "HIV-1/Mycobacterium tuberculosis Coinfection Immunology: How Does HIV-1 Exacerbate Tuberculosis?". Infection and Immunity 79 (4): 1407–1417. doi:10.1128/iai.01126-10. PMID 21245275. 
• Dyer T.; Shoptaw S.; Guadamuz T.; Plankey M.; Kao U.; Ostrow D.; Chmiel J.; Herrick A. et al. (2012). "Application of Syndemic Theory to Black Men Who Have Sex with Men in the Multicenter AIDS Cohort Study". Journal of Urban Health 89 (4): 697–708. doi:10.1007/s11524-012-9674-x. PMID 22383094. 
• Easton, Delia 2004 The Urban Poor: Health Issues. Encyclopedia of Medical Anthropology, Volume 1, pp. 207–213. New York: Kluwer Academic/Plenum Publishers.
• Edberg Mark; Cleary Sean; Vyas Amita (2010). "A Trajectory Model for Understanding and Assessing Health Disparities in Immigrant/Refugee Communities". Immigration and Minority Health 13 (3): 576–584. doi:10.1007/s10903-010-9337-5. 
• Engel Jeffery (2007). "Pandemic Influenza: The Critical Issues and North Carolina's Preparedness Plan". North Carolina Medical Journal 68 (1): 32–37. 
• Ezeamama A.; McGarvey S.; Acosta L.; Zierler S.; Manalo D.; Wu H-W.; Kurtis J.; Mor V. et al. (2008). "The Synergistic Effect of Concomitant Schistosomiasis, Hookworm, and Trichuris Infections on Children's Anemia Burden". PLoS Neglected Tropical Diseases 2 (6): e245. doi:10.1371/journal.pntd.0000245. 
• Fama Rosemary, Rosenbloom Margaret, Nichols Pfefferbaum, Nolan B., Adolf Sullivan, Edith (2009). "Working and Episodic Memory in HIV Infection, Alcoholism, and Their Comorbidity: Baseline and 1-Year Follow-Up Examinations". Alcoholism: Clinical and Experimental Research 33 (10): 1815–1825. doi:10.1111/j.1530-0277.2009.01020.x. 
• Fasula Amy; Miller Kim; Sutton Madeline (2009). "An early warning sign: sexually transmissible infections among young African American women and the need for preemptive, combination HIV prevention". Sexual Health 6: 261–263. doi:10.1071/sh09084. 
• Ferlatte, Oliver, Hottes, Travis, Trussler, Terry and Marchand, Rick 2013 Evidence of a Syndemic Among Young Canadian Gay and Bisexual Men: Uncovering the Associations Between Anti-gay Experiences, Psychosocial Issues, and HIV Risk. AIDS and Behavior epub ahead of publication: doi:10.1007/s10461-013-0639-.
• Fleming F., Brooker S., Geiger S., Caldas I., Correa-Oliveira R., Hotez P., Bethony (2006). "Synergistic associations between hookworm and other helminth species in a rural community in Brazil". Tropical Medicine and International Health 11: 56–64. doi:10.1111/j.1365-3156.2005.01541.x. PMID 16398756. 
• Florey Lia, King Charles, Dyke Van, Melissa Muchiri, Eric Mungai, Peter Zimmerman, Peter, Wilson Mark (2012). "Partnering Parasites: Evidence of Synergism between Heavy Schistosoma haematobium and Plasmodium Species Infections in Kenyan Children". PLoS Neglected Tropical Diseases 6 (7): e1723. doi:10.1371/journal.pntd.0001723. 
• Fiorella, Kathryn 2013 Considering the Complexity in HIV/AIDS and the Environment. American Journal of Public Health 103(9):e1-e1 (in press).
• Friedman, M. Reuel, Kutz, Steven, Buttram, Mance, Wei, Chongyi, Silvestre, Anthony, and Stall, Ron 2013 HIV Risk Among Substance-Using Men Who Have Sex with Men and Women (MSMW): Findings from South Florida. AIDS and Behavior (in press).
• Garcia J.; Hromi-Fiedler A.; Mazur R.; Marquis G.; Sellen D.; Lartey A; Pérez-Escamilla R. (2013). "Persistent household food insecurity, HIV, and maternal stress in Peri-Urban Ghana". BMC Public Health 13: 215. doi:10.1186/1471-2458-13-215. PMID 23497026. 
• Geldmacher C.; Zumla A.; Hoelscher M. (2012). "Interaction between HIV and Mycobacterium tuberculosis: HIV-1-induced CD4 T-cell depletion and the development of active tuberculosis". Current Opinion in HIV and AIDS 7 (3): 268–274. doi:10.1097/coh.0b013e3283524e32. https://zenodo.org/record/895917. 
• Gerberding J (2005). "Protecting Health — The New Research Imperative". Journal of the American Medical Association 294 (11): 1403–1406. doi:10.1001/jama.294.11.1403. PMID 16174702. 
• Gerns Helen; Sangare Laura; Walson Judd (2012). "Integration of Deworming into HIV Care and Treatment: A Neglected Opportunity". PLoS Neglected Tropical Diseases 6 (7): e1738. doi:10.1371/journal.pntd.0001738. 
• Getahun Haileyesus; Raviglione Mario; Varma Jay; Cain Kevin; Samandari Taraz; Popovic Tanja; Frieden Thomas (2012). "CDC Grand Rounds: the TB/HIV Syndemic". Morbidity and Mortality Weekly Report (MMWR) 61 (26): 484–489. 
• Gielen A.; Ghandour R.; Burke J.; Mahoney P.; McDonnell K.; O'Campo P. (2007). "HIV/AIDS and Intimate Partner Violence: Intersecting Women's Health Issues in the United States". Trauma, Violence and Abuse 8 (2): 179–198. doi:10.1177/1524838007301476. 
• González-Guarda Rosa (2009). "The Syndemic Orientation: Implications for Eliminating Hispanic Health Disparities". Hispanic Health Care International 7 (3): 114–115. doi:10.1891/1540-4153.7.3.114. 
• Gilbert, Louisa, Primbetova, Sholpan, Nikitin, Danil, Hunt, Timothy, Terlikbayeva, Assel, Momenghalibaf, Azzi, Murodali, Ruziev and El-Bassel, Nabila 2013 Redressing the epidemics of opioid overdose and HIV among people who inject drugs in Central Asia: The need for a syndemic approach. Drug and Alcohol Dependence (in press).
• González-Guarda Rosa; Florom-Smith A.; Thomas T. (2011). "A syndemic model of substance abuse, intimate partner violence, HIV infection, and mental health among Hispanics". Public Health Nursing 28 (4): 366–378. doi:10.1111/j.1525-1446.2010.00928.x. 
• González-Guarda Rosa; McCabe B.; Florom-Smith A.; Cianelli R.; Peragallo N. (2011). "Substance Abuse, Violence, HIV, and Depression: An Underlying Syndemic Factor Among Latinas". Nursing Research 60 (3): 182–189. doi:10.1097/nnr.0b013e318216d5f4. 
• González-Guarda Rosa, Santis De, Joseph, Vasquuez Elias (2013). "Sexual orientation and demographic, cultural and psychological factors associated with the perpetration and victimization of intimate partner violence among Hispanic men". Issues in Mental Health Nursing 34 (2): 103–109. doi:10.3109/01612840.2012.728280. PMID 23369121. 
• González-Guarda McCabe, Brian Vermeesch, Amber Cianelli, Rosina Florom-Smith, Aubrey, Nilda Peragallo (2013). "Cultural Phenomena and the Syndemic Factor: Substance Abuse, Violence, HIV, and Depression Among Hispanic Women". Annals of Anthropological Practice 36 (2): 212–231. doi:10.1111/napa.12001. 
• González-Guarda Rosa (2013). "Pushing the Syndemic Research Agenda Forward: a Comment on Pitpitan et al.". Annals of Behavioral Medicine 45 (2): 135–136. doi:10.1007/s12160-012-9464-4. 
• Grund Jean-Paul; Latypov Alisher; Harris Magdalena (2012). "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia". International Journal of Drug Policy 24 (4): 265–274. doi:10.1016/j.drugpo.2013.04.007. PMID 23726898. 
• Guadamuz, Thomas, Friedman, Mark, Marshal, Michael, Herrick, Amy, Lim, Sin How, Wei, Chongyi, and Stall, Ron 2013 Health, Sexual Health, and Syndemics: Toward a Better Approach to STI and HIV Preventive Interventions for Men Who Have Sex with Men (MSM) in the United States. In S. Aral, K. Fenton, J. Lipshuz, Eds. The New Public Health and STD/HIV Prevention: Personal, Public and Health Systems Approaches. New York: Springer Sciences and Business Media.
• Guadamuz, T.E., McCarthy, K., Wimonsate, W., Thienkrua, W., Varangrat, A., Chaikummao, S., Sangiamkittikul, A., Stall, R.D., van Griensven, F. 2014 Psychosocial Health Conditions and HIV Prevalence and Incidence in a Cohort of Men Who have Sex with Men in Bangkok, Thailand: Evidence of a Syndemic Effect. "AIDS and Behavior" [Published online ahead of print] doi:10.1007/s10461-014-0826-8
• Halkitis P.; Moeller R.; Siconolfi D.; Storholm E.; Solomon T.; Bub K. (2012). "Measurement Model Exploring a Syndemic in Emerging Adult Gay and Bisexual Men". AIDS and Behavior 17 (2): 662–673. doi:10.1007/s10461-012-0273-3. 
• Halkitis Perry; Kupprat Sandra; Hampton Melvin; Perez-Figueroa Rafael; Kindon Molly; Eddy Jessica; Ompad Danielle (2013). "Evidence for a Syndemic in Aging HIV-Positive Gay, Bisexual, and Other MSM: Implications for a Holistic Approach to Prevention and Health Care". Annals of Anthropological Practice 36 (2): 363–384. doi:10.1111/napa.12009. 
• Hardin Amy; Crandall Philip; Stankus Tony (2011). "The Zoonotic Tuberculosis Syndemic: A Literature Review and Analysis of the Scientific Journals Covering a Multidisciplinary Field That Includes Clinical Medicine, Animal Science, Wildlife Management, Bacterial Evolution, and Food Safety". Science & Technology Libraries 30 (1): 20–57. doi:10.1080/0194262x.2010.523666. 
• Hein, Casey and Small, Doreen 2007 Combating Diabetes, Obesity, Periodontal Disease and Interrelated Inflammatory Conditions with a Syndemic Approach. Available online at:https://web.archive.org/web/20070928204637/http://www.healthdecisions.org/Dental/News/default.aspx?doc_id=109688.
• Herrick Amy; Lim Sin; Wei Chongyi; Smith Helen; Guadamuz Thomas; Friedman Mark; Stall Ron (2011). "Resilience as an Untapped Resource in Behavioral Intervention Design for Gay Men". AIDS and Behavior 15 (Suppl 1): S25–S29. doi:10.1007/s10461-011-9895-0. 
• Herrick Amy; Lim Sin; Plankey Michael; Chmiel Joan; Guadamuz Thomas; Kao Uyen; Shoptaw Steven; Carrico Adam et al. (2013). "Adversity and Syndemic Production Among Men Participating in the Multicenter AIDS Cohort Study: A Life-Course Approach". American Journal of Public Health 103 (1): 79–85. doi:10.2105/ajph.2012.300810. PMID 23153154. 
• Herring, D Ann 2008 Viral Panic, Vulnerability and the Next Pandemic. In Health, Risk and Adversity, Catherine Panter-Brick and Agustín Fuentes, Eds, pp 78–100. Oxford, U.K.: Berghahn Books, 2008.
• Highet Megan (2010). "It Depends on Where You Look": The Unusual Presentation of Scurvy and Smallpox Among Klondike Gold Rushers as Revealed Through Qualitative Data Sources". Past Imperfect: The History and Classics Graduate Student Journal 16: 3–34. 
• Himmelgreen David; Romero-Daza Nancy; Turkon David; Watson Sharon; Okello-Uma Ipolto; Sellen Daniel (2009). "Addressing the HIV/AIDS-food insecurity syndemic in sub-Saharan Africa". African Journal of AIDS Research 8 (4): 401–412. doi:10.2989/ajar.2009.8.4.4.1041. 
• Himmelgreen, David and Romero-Daza, Nancy 2010 The Global Food Crisis, HIV/AIDS, and Home Gardens. Environment: Science and Policy for Sustainable Development June–July. Online at: http://www.environmentmagazine.org/Bytes%20of%20Note/Bytes-index.html.
• Himmelgreen David; Romero-Daza Nancy; Amador Edgar; Pace Cynthia (2013). "Tourism, Economic Insecurity, and Nutritional Health in Rural Costa Rica:Using Syndemic Theory to Understand the Impact of the Globalizing". Annals of Anthropological Practice 36 (2): 344–362. doi:10.1111/napa.12008. 
• Iacopin Anthony (2009). "New 'Syndemic' Paradigm for Interprofessional Management of Chronic Inflammatory Disease". Journal of the Canadian Dental Association 75 (9): 632–633. 
• Ivan Emil; Crowther Nigel; Mutimura Eugene; Obado Osuwat Lawrence; Janssen Saskia; Grobusch Martin P (2013). "Helminthic Infections Rates and Malaria in HIV-Infected Pregnant Women on Anti-Retroviral Therapy in Rwanda". PLoS Neglected Tropical Diseases 7 (8): e2380. doi:10.1371/journal.pntd.0002380. 
• Jie Wu; Ciyong Lu; Xueqing Deng; Hui Wang; Lingyao Hong (2012). "A Syndemic of Psychosocial Problems Places the MSM (Men Who Have Sex with Men) Population at Greater Risk of HIV Infection". PLoS ONE 7 (3): e32312. doi:10.1371/journal.pone.0032312. PMID 22479319. 
• Jittimanee Sirinapha; Nateniyom Sriprapa; Kittikraisak Wanitchaya; Burapat Channawong; Akksilp Somsak; Chumpathat Nopphanath; Sirinak Chawin; Sattayawuthipong Wanchai et al. (2009). "Social Stigma and Knowledge of Tuberculosis and HIV among Patients with Both Diseases in Thailand". PLoS ONE 4 (7): e6360. doi:10.1371/journal.pone.0006360. 
• Johnson Roger B (2007). "Periodontitis as a Component of Hyperinflammation: Treating Periodontitis in Obese Diabetic Patients". Compendium 28 (9): 500–505. 
• Kant L (2003). "Diabetes Mellitus-Tuberculosis: The Brewing Double Trouble". Indian Journal of Tuberculosis 50 (4): 83–84. 
• Kelly, Patricia, Cheng, An-Lin, Spencer-Carver, Elaine and Ramaswamy, Megha 2012 A Syndemic Model of Women Incarcerated in Community Jails. Public Health Nursing (in press) doi:10.1111/phn.12056.
• Klein High (2011). "Using a Syndemics Theory Approach to Study HIV Risk Taking in a Population of Men Who Use the Internet to Find Partners for Unprotected Sex". American Journal of Men's Health 5 (6): 466–476. doi:10.1177/1557988311398472. 
• Klein, Hugh 2013 Condom Use Self-Efficacy and HIV Risk Practices Among Men Who Use the Internet to Find Male Partners for Unprotected Sex. American Journal of Men's Health (in press).
• Kline Nolan (2013). "There's Nowhere I Can Go to Get Help, and I have Tooth Pain Right Now": The Oral Health Syndemic Among Migrant Farmworkers in Florida". Annals of Anthropological Practice 36 (2): 385–399. doi:10.1111/napa.12010. 
• Kurtz Steven (2008). "Unexpected Additional Evidence For Syndemic Theory". Journal of Psychoactive Drugs 40 (4): 513–521. doi:10.1080/02791072.2008.10400657. 
• Kurtz Steven; Buttram Mance; Surratt Hilary; Stall Ronald (2012). "Resilience, Syndemic Factors, and Serosorting Behaviors among HIV-Positive and HIV-Negative Substance-Using MSM". AIDS Education and Prevention 24 (3): 193–205. doi:10.1521/aeap.2012.24.3.193. 
• Kwan C.; Ernst J. (2011). "HIV and Tuberculosis: A Deadly Human Syndemic". Clinical Microbiology Reviews 24 (2): 351–376. doi:10.1128/cmr.00042-10. 
• Laserson, K. and Wells, C. 2007 Reaching the Targets for Tuberculosis Control: The impact of HIV. Bulletin of the World Health Organization 85(5). Available on at: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862007000500016&lng=&nrm=iso.
• Leuer Marie; Abonyi Sylvia; Smadu Marlene (2013). "A Syndemic Perspective of Negative Childhood Outcomes: Parenting in a "Perfect Storm" of Disadvantaged Conditions". Journal of Poverty 17 (2): 198–216. doi:10.1080/10875549.2013.775997. 
• Liao Meizhen; Kang Dianmin; Tao Xiaorun; Cox Catherine; Qian Yuesheng; Wang Guoyong; Yang Cui; Zhu XiaoYan et al. (2014). "Syndemics of syphilis, HCV infection, and methamphetamine use along the east coast of China". BMC Public Health 14: 172. doi:10.1186/1471-2458-14-172. PMID 24533587. 
• Lim, S.H. Herrick, A., Guadamuz, T., Kao, U., Plankey, M., Ostrow, D., Shoptaw, S. and Stall, R. 2010 Childhood sexual abuse, gay-related victimization, HIV infection and syndemic productions among men who have sex with men (MSM): findings from the Multicenter AIDS Cohort Study (MACS). Presented at the XVIII International AIDS Conference, July 18–23. Vienna, Austria.
• Limmahakhun S.; Chaiwarith R.; Nuntachit N.; Sirisanthana T.; Supparatpinyo K. (2012). "Treatment outcomes of patients co-infected with tuberculosis and HIV at Chiang Mai University Hospital, Thailand". International Journal of STD and AIDS 23 (6): 414–418. doi:10.1258/ijsa.2012.011291. 
• Littleton, Juditith and Julia Park 2009 Tuberculosis and syndemics: Implications for Pacific health in New Zealand. Social Science & Medicine (11):1674-1680.
• Littleton, Judith, Julie Park, Ann Herring and Tracy Farmer 2008 Multiplying and Dividing Tuberculosis in Canada and Aotearoa New Zealand, Research in Anthropology and Linguistics e3. University of Auckland.
• Littleton Judith; Park Julie; Nelesone Tekaai (2013). "Helminths and TB in Polynesia: The Implications for Health Practice". Annals of Anthropological Practice 36 (2): 273–292. doi:10.1111/napa.12004. 
• Lyons, Thomas, Johnson, Amy and Garofalo, Robert 2013 "What Could Have Been Different": A Qualitative Study of Syndemic Theory and HIV Prevention Among Young Men Who Have Sex With Men. Journal of HIV/AIDS & Social Services (in press).
• Marshall Mac (2005). "Carolina in the Carolines: A Survey of Patterns and Meanings of Smoking on a Micronesian Island". Medical Anthropology Quarterly 19 (4): 354–382. doi:10.1525/maq.2005.19.4.365. 
• Martin, Yolanda 2013 The Syndemics of Removal: Trauma and Substance Abuse. In Outside Justice: Immigration and the Criminalizing Impact of Changing Policy and Practice edited by David Brotherton, Daniel Stageman and Shirley Leyro. New York: Springer, 91-107.
• Mavridis, Agapi 2008 Tuberculosis and Syndemics: Implications for Winnipeg, Manitoba. In Multiplying and Dividing Tuberculosis in Canada and Aotearoa New Zealand, Judith Littleton, Julie Park, Ann Herring and Tracy Farmer, Eds. Research in Anthropology and Linguistics e3: 43-53.
• Mazigo Humphrey; Nuwaha Fred; Wilson Shona; Kinung'hi Safari; Morona Domenica; Waihenya Rebecca; Heukelbach Jorg; Dunne David (2013). "Epidemiology and interactions of Human Immunodeficiency Virus – 1 and Schistosoma mansoni in sub-Saharan Africa". Infectious Diseases of Poverty 2: 2. doi:10.1186/2049-9957-2-2. 
• MacQueen, Kate 2002 Anthropology and Public Health. Encyclopedia of Public Health. New York: Macmillan Reference.
• McKenzie, Kellye, Mbajah, Joy, Seegers, Angela, and Davis, Celeste 2008 The Landscape of HIV/AIDS among African American Women in the United States. NASTAD National Alliance of State and Territorial AIDS Directors. Issue Brief No. 1:1-12.
• Mercado, Susan, Kirsten Havemann, Keiko Nakamura, Andrew Kiyu, Mojgan Sami, Roby Alampay, Ira Pedrasa, Divine Salvador, Jeerawat Na Thalang, and Tran Le Thuey 2007 Responding to the Health Vulnerabilities of the Urban Poor in the ‘New Urban Settings’ of Asia. Presented at Improving Urban Population Health Systems, sponsored by the Center for Sustainable Urban Development, July.
• Meyer, Jaimie P.; Springer, Sandra A.; Altice, Frederick L. (July 2011). "Substance Abuse, Violence, and HIV in Women: A Literature Review of the Syndemic". Journal of Women's Health (Mary Ann Liebert, Inc.) 20 (7): 991–1006. doi:10.1089/jwh.2010.2328. https://dx.doi.org/10.1089/jwh.2010.2328. 
• Millstein, Bobby 2001 Introduction to the Syndemics Prevention Network. Atlanta: Centers for Disease Control and Prevention.
• Millstein, Bobby 2004 Syndemics. In: Encyclopedia of Evaluation. Sandra Mathison, Ed. Pp. 404–405. Thousand Oaks, CA: Sage Publications.
• Moellera Robert; Halkitisa Perry; Surrencea Katie (2011). "The Interplay of Syndemic Production and Serosorting in Drug-Using Gay and Bisexual Men". Journal of Gay & Lesbian Social Services 23 (1): 89–106. doi:10.1080/10538720.2010.538007. 
• Mizuno Y.; Borkowf C.; Millett G.; Bingham T.; Ayala G.; Stueve A. (2011). "Homophobia and Racism Experienced by Latino Men Who Have Sex with Men in the United States: Correlates of Exposure and Associations with HIV Risk Behaviors". AIDS and Behavior 16 (3): 724–735. doi:10.1007/s10461-011-9967-1. 
• Morano Jamie; Gibson Britton; Altice Fredrick (2013). "The Burgeoning HIV/HCV Syndemic in the Urban Northeast: HCV, HIV, and HIV/HCV Coinfection in an Urban Setting". PLOS ONE 8 (5): e64321. doi:10.1371/journal.pone.0064321. PMID 23691197. 
• Morens D.; Taubenberger J.; Fauci A. (2008). "Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness". The Journal of Infectious Diseases 198 (7): 962–970. doi:10.1086/591708. PMID 18710327. 
• Mustanski Brian; Garofalo Robert; Herrick Amy; Donenberg Geri (2007). "Psychosocial health problems increase risk for HIV among urban young men who have sex with men: Preliminary evidence of a syndemic in need of attention". Annals of Behavioral Medicine 34 (1): 37–45. doi:10.1007/bf02879919. 
• Mustanski Brian; Andrews Rebecca; Herrick Amy; Stall Ron; Schnarrs Phillip (2014). "A Syndemic of Psychosocial Health Disparities and Associations With Risk for Attempting Suicide Among Young Sexual Minority Men". American Journal of Public Health 104 (2): 287–294. doi:10.2105/ajph.2013.301744. PMID 24328641. 
• Myslobodsky M.; Eldan A. (2010). "Winning a Won Game: Caffeine Panacea for Obesity Syndemic". Current Neuropharmacology 8 (2): 149–160. doi:10.2174/157015910791233213. 
• Nichter, Mark 2003 Harm Reduction, Harm Reduction, Ecosocial Epidemiology, Ecosocial Epidemiology, and Syndemics. Online at: http://www.csiss.org/events/meetings/risk-perception/docs/nichter_presentation.pdf.
• Noymer, Andrew and Michel Garenne 2000 The 1918 Influenza epidemic's effects on sex differentials in mortality in the United States.Population and Development Review 26(3):565–581 Online at: http://www.demog.berkeley.edu/~andrew/1918/PDR_1918_flu.pdf.
• O’Leary, Ann, Jemmott III, John, Stevens, Robin, Rutledge, Scott and Icard, Larry 2014 Optimism and Education Buffer the Effects of Syndemic Conditions on HIV Status Among African American Men Who Have Sex with Men. AIDS & Behavior [Epub ahead of print] doi:10.1007/s10461-014-0708-0.
• Operario Don; Nemoto Tooru (2010). "HIV in Transgender Communities: Syndemic Dynamics and a Need for Multicomponent Intervention". JAIDS: Journal of Acquired Immune Deficiency Syndromes 55: S91–S93. doi:10.1097/qai.0b013e3181fbc9ec. 
• Ostrach Bayla; Singer Merrill (2012). "At Special Risk: Biopolitical Vulnerability and HIV Syndemics Among Women". Health Sociology Review. doi:10.5172/hesr.2012.1532-1569. 
• Ostrach Bayla; Merrill Singer (2013). "Syndemics of War: Malnutrition-Infectious Disease Interactions and the Unintended Health Consequences of Intentional War Policies". Annals of Anthropological Practice 36 (2): 256–272. doi:10.1111/napa.12003. 
• Padilla Mark; Guilamo-Ramos Vincent; Godbole Ramona (2011). "A Syndemic Analysis of Alcohol Use and Sexual Risk Behavior Among Tourism Employees in Sosúa, Dominican Republic". Qualitative Health Review 22 (1): 89–102. doi:10.1177/1049732311419865. 
• Pablos-Mendez A.; Blustein J.; Knirsch C. (1997). "The role of diabetes mellitus in the higher prevalence of tuberculosis among Hispanics". American Journal of Public Health 87: 574–579. doi:10.2105/ajph.87.4.574. 
• Parsons Jeffrey; Grov C.; Golub S. (2011). "'Sexual Compulsivity, Co-Occurring Psychosocial Health Problems, and HIV Risk Among Gay and Bisexual Men: Further Evidence of a Syndemic". American Journal of Public Health 102 (1): 156–162. doi:10.2105/ajph.2011.300284. PMID 22095358. 
• Patel Pragnesh; Voigt Michael (2002). "Prevalence and interaction of hepatitis B and latent tuberculosis in Vietnamese immigrants to the United States". The American Journal of Gastroenterology 97: 1198–1203. doi:10.1111/j.1572-0241.2002.05704.x. 
• Perez A.; Brown H.; Restrepo B. (2006). "Association between tuberculosis and diabetes in the Mexican border and non-border regions of Texas". American Journal of Tropical Medicine and Hygiene 74: 604–611. 
• Pitpitan E.; Kalichman S.; Eaton L.; Cain D.; Sikkema K.; Watt M.; Skinner D.; Pieterse D. (2012). "Co-occurring Psychosocial Problems and HIV Risk Among Women Attending Drinking Venues in a South African Township: A Syndemic Approach". Annals of Behavioral Medicine 45 (2): 153–162. doi:10.1007/s12160-012-9420-3. 
• Ponce-De-Leon A.; Garcia-Garcia L.; Garcia-Sancho M.; Gomez-Perez F.; Valdespino-Gomez J. (2004). "Tuberculosis and diabetes in southern Mexico". Diabetes Care 27: 1584–1590. doi:10.2337/diacare.27.7.1584. 
• Raso G.; Luginbuhl A.; Adjoua C.; Tian-Bi N.; Silué K.; Matthys B.; Vounatsou P.; Wang Y. et al. (2004). "Multiple parasite infections and their relationship to self-reported morbidity in a community of rural Côte d'Ivoire". International Journal of Epidemiology 33: 1092–1102. doi:10.1093/ije/dyh241. 
• Reitmanova Sylvia; Gustafson Diana (2012). "Coloring the white plague: a syndemic approach to immigrant tuberculosis in Canada". Ethnicity and Health 17 (4): 403–418. doi:10.1080/13557858.2011.645156. 
• Ribera Joan Muela; Hausmann-Muela Susanna (2011). "The Straw that Breaks the Camel's Back Redirecting Health-Seeking Behavior Studies on Malaria Vulnerability". Medical Anthropology Quarterly 25 (1): 103–121. doi:10.1111/j.1548-1387.2010.01139.x. 
• Reddi Anand; Powers Matthew; Andreas Thyssen (2012). "HIV/AIDS and food insecurity: deadly syndemic or an opportunity for healthcare synergism in resource-limited settings of sub-Saharan Africa?". AIDS 26 (1): 115–7. doi:10.1097/qad.0b013e32834e14ac. PMID 22126815. 
• Rock Melanie; Buntain Bonnie; Hatfield Jennifer; Hallgrimsson Benedikt (2009). "Animal-human connections, 'one health,' and the syndemic approach to prevention". Social Science & Medicine 68 (6): 991–995. doi:10.1016/j.socscimed.2008.12.047. 
• Rock Melanie (2013). "Connecting Lives: Reflections on a Syndemic Approach to Prevention Involving Research on How People Relate to Pets". Annals of Anthropological Practice 36 (2): 310–325. doi:10.1111/napa.12006. 
• Romero-Daza Nancy; Baldwin Julie; Lescano Celia; Williamson Heather; Tilley David; Chan Isabella; Tewell Mackenzie; Palacios Wilson (2013). "Syndemic Theory as a Model for Training and Mentorship to Address HIV/AIDS Among Latinos in the United States". Annals of Anthropological Practice 36 (2): 232–255. doi:10.1111/napa.12002. 
• Rosenberg, Rhonda and Malow, Robert 2006 Hardness of Risk: Poverty, Women and New Targets for HIV/AIDS Prevention. Psychology & AIDS Exchange 34:3-4, 9, & 12.
• Rhodes, Jeselyn 2010 Early Syphilis and HIV Syndemic in Nashville/Davidson Co., Tennessee: Implications for Improving Syphilis Screening for People Living with and at Risk for HIV. Presented at the National STD Prevention Conference. Atlanta, GA.
• Ruiz Juan; Egli Marc (2010). "Metabolic Syndrome, Diabetes Mellitus and Vulnerability: A Syndemic Approach to Chronic Diseases". Revue Medicale de la Suisse Romande 6 (271): 2205–2208. 
• Russell Beth, Eaton Lisa, Petersen, Williams Petal (2013). "Intersecting Epidemics Among Pregnant Women: Alcohol Use, Interpersonal Violence, and HIV Infection in South Africa". Current HIV/AIDS Reports 10 (1): 103–110. doi:10.1007/s11904-012-0145-5. 
• Safren Steven; Reisner Sari; Herrick Amy; Mimiaga Matthew; Stall Ronald (2010). "Mental Health and HIV Risk in Men Who Have Sex With Men". Journal of Acquired Immune Deficiency Syndromes 55: S74–S77. doi:10.1097/qai.0b013e3181fbc939. 
• Safren, Steven, Blashill, Aaron and O’Cleirigh, Conall 2011 Promoting the Sexual Health of MSM in the Context of Comorbid Mental Health Problems. AIDS and Behavior Supplement 1:S30-34.
• Sanchez, Melissa, Scheer, Susan, Shallow, Sue, Pipkin, Sharon and Huang, Sandra 2014 Epidemiology of the Viral Hepatitis-HIV Syndemic in San Francisco: A Collaborative Surveillance Approach. Public Health Reports 129(Supplement 1):95-101.
• Santos, Glenn-Milo, Do, Tri, Beck, Jack, Makofane, Keletso, Arreola, Sonya, Pyun, Thomas, Herbert, Pato, Wilson, Patrick and Ayala, George 2014 Sexually Transmitted Infections doi:10.1136/sextrans-2013-051318
• Sathekge Mike, Maes Alex, Van, de Wiele Christophe (2013). "FDG-PET Imaging in HIV Infection and Tuberculosis". Seminars in Nuclear Medicine 43 (5): 349–366. doi:10.1053/j.semnuclmed.2013.04.008. 
• Sattenspiel, Lisa and Herring, Ann 2010 Emerging Themes in Anthropology and Epidemiology: Geographic Spread, Evolving Pathogens and Syndemics. In Clark Spencer Larsent, ED. A Companion to Biological Anthropology. Malden, MA: Wiley.
• Sattenspiel Lisa; Mamelund Svenn-Erik (2013). "Cocirculating Epidemics, Chronic Health Problems, and Social Conditions in Early 20th Century Labrador and Alaska". Annals of Anthropological Practice 36 (2): 400–419. doi:10.1111/napa.12011. 
• Scheiblauer H.; Reinacher M; Tashiro M.; Rott R. (1992). "Interactions Between Bacteria and Influenza A Virus in the Development of Influenza Pneumonia". Journal of Infectious Diseases 166: 783–791. doi:10.1093/infdis/166.4.783. 
• Scrimshaw, Neville, Taylor Carl, and Gordon, John 1968 Interactions of Nutrition and Infection. Geneva: World Health Organization
• Secor W.; Karanja D.; Colley D. (2004). "Interactions between Schistosomiasis and Human Immunodeficiency Virus in Western Kenya". Memorias do Instituto Oswaldo Cruz 99 (5 Suppl. 1): 93–95. doi:10.1590/s0074-02762004000900016. 
• Seth Dipankar; Sarkar Amit; Mitra Debalina (2014). "Nanomedicine to Counter Syndemic Tuberculosis and HIV Infection: Current Knowledge and State of Art". Nanoscience and Nanoengineering 2 (1): 1–9. 
• Sethi Sanjeev (2002). "Bacterial Pneumonia. Managing a Deadly Complication of Influenza in Older Adults with Comorbid Disease". Geriatrics 57 (3): 56–61. 
• Shaikh M.; Singla R.; Khan N.; Sharif N.; Saigh M. (2003). "Does Diabetes Alter the Radiological Presentation of Pulmonary Tuberculosis". Saudi Medical Journal 24 (3): 278–281. 
• Sheretz R.; Reagan D.; Hampton K.; Robertson K.; Streed S.; Hoen H.; Thomas R.; Gwaltney J. Jr (1996). "A Cloud Adult: The Staphylococcus aureus-virus Interaction Revisited". Annals of Internal Medicine 124 (6): 539–547. doi:10.7326/0003-4819-124-6-199603150-00001. 
• Shields, Sara and Lucy M. Candib, Eds. 2010 Women-Centered Care in Pregnancy and Childbirth. Oxon, United Kingdom: Radcliffe Publishing Ltd.
• Sibley, Candace Danielle 2011 A Multi-Methodological Study of a Possible Syndemic among Female Adult Film Actresses. MSPH Thesis University of South Florida.
• Sikkema Kathleen; Watt Melissa; Meade Christina; Ranby Krista; Kalichman Seth; Skinner Donald; Pieterse Desiree (2011). "Mental Health and HIV Risk Behavior Among Patrons of Alcohol Serving Venues in Cape Town, South Africa". Journal of Acquired Immune Deficiency Syndromes 57 (3): 230–237. doi:10.1097/qai.0b013e3182167e7a. 
• Singer Merrill (1994). "AIDS and the Health Crisis of the US Urban Poor: The Perspective of Critical Medical Anthropology". Social Science and Medicine 39 (7): 931–948. doi:10.1016/0277-9536(94)90205-4. 
• Singer Merrill (1996). "A Dose of Drugs, a Touch of Violence, A Case of AIDS: Conceptualizing the SAVA Syndemic". Free Inquiry in Creative Sociology 24 (2): 99–110. 
• Singer, Merrill 2004 Critical Medical Anthropology. In Encyclopedia of Medical Anthropology: Health and Illness in the World’s Cultures. Vol. 1:23-30. Carol Ember and Melvin Ember, (eds). New York: Kluwer.
• Singer, Merrill 2006 Syndemics. Encyclopedia of Epidemiology. Sarah Boslaugh (ed). Thousand Oaks, CA:Sage Publications, Inc.
• Singer Merrill (2006). "A Dose of Drugs, A Touch of Violence, A Case of AIDS, Part 2: Further Conceptualizing the SAVA Syndemic". Free Inquiry in Creative 34 (1): 39–56. 
• Singer, Merrill 2008 The Perfect Epidemiological Storm: Food Insecurity, HIV/AIDS and Poverty in Southern Africa. Anthropology Newsletter(American Anthropological Association) 49(7): 12 & 15 October.
• Singer, Merrill 2008 Drug-related Syndemics and the Risk Environment: Assessing Street risk among Hispanics in Hartford. Presented at the 8th Annual National Hispanic Science Network on Drug Abuse. Bethesda, Maryland.
• Singer, Merrill 2009 Desperate Measures: A Syndemic Approach to the Anthropology of Health in a Violent City. In Global Health in the Time of Violence, Barbara Rylko-Bauer, Linda Whiteford, and Paul Farmer, Editors. Sante Fe, NM: SAR Press.
• Singer Merrill (2009). "Doorways in Nature: Syndemics, Zoonotics, and Public Health: A Commentary on Rock, Buntain, Hatfield & Hallgrímsson". Social Science & Medicine 68 (6): 996–999. doi:10.1016/j.socscimed.2008.12.041. 
• Singer Merrill (2009). "Pathogens Gone Wild?: Medical Anthropology and the "Swine Flu" Pandemic". Medical Anthropology 28 (3): 199–206. doi:10.1080/01459740903070451. 
• Singer Merrill (2010). "Pathogen-Pathogen Interaction: A Syndemic Model of Complex Biosocial Processes in Disease". Virulence 1 (1): 10–18. doi:10.4161/viru.1.1.9933. 
• Singer, Merrill 2010 Ecosyndemics: Global Warming and the Coming Plagues of the 21st Century. In Plagues: Models and Metaphors in the Human ‘Struggle’ with Disease, D. Ann Herring and Alan C. Swedlund, Editors, pp. 21–38. London: Berg.
• Singer, Merrill 2011 Double Jeopardy: Vulnerable Children and the Possible Global Lead Poisoning/Infectious Disease Syndemic. In Routledge Handbook in Global Health, Richard Parker and Marni Sommer, Editors, pp. 154–161. New York: Routledge.
• Singer, Merrill 2011 The Infectious Disease Syndemics of Crack Cocaine. Journal of Equity in Health (in press).
• Singer Merrill (2011). "Toward a Critical Biosocial Model of Ecohealth in Southern Africa: The HIV/AIDS and Nutrition Insecurity Syndemic". Annals of Anthropological Practice 35 (1): 8–27. doi:10.1111/j.2153-9588.2011.01064.x. 
• Singer, Merrill and Baer, Hans 2007 Introducing Medical Anthropology: A Discipline in Action. AltaMira/ Rowman Littlefield Publishers, Inc.
• Singer Merrill; Clair Scott (2003). "Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context". Medical Anthropology Quarterly 17 (4): 423–441. doi:10.1525/maq.2003.17.4.423. 
• Singer Merrill; Erickson Pamela; Badiane Louise; Diaz Rosemary; Ortiz Dueidy; Abraham Traci; Nicolaysen Anna Marie (2006). "Syndemics, Sex and the City: Understanding Sexually Transmitted Disease in Social and Cultural Context". Social Science and Medicine 63 (8): 2010–2021. doi:10.1016/j.socscimed.2006.05.012. PMID 16782250. 
• Singer, Merrill, Herring, D. Ann, Littleton, Judith, and Rock, Melanie 2011 Syndemics in Global Health. In A Companion to Medical Anthropology, Merrill Singer and Pamela I. Erickson, Editors, pp. 219–249. Malden, MA: Wiley-Blackwell.
• Singer Merrill; Snipes Charlene (1992). "Generations of Suffering: Experiences of a Pregnancy and Substance Abuse Treatment Program". Journal of Health Care for the Poor and Underserved 3 (1): 235–239. doi:10.1353/hpu.2010.0852. 
• Singer Merrill; Bulled Nicola; Ostrach Bayla (2013). "Syndemics and Human Health: Implications for Prevention and Intervention". Annals of Anthropological Practice 36 (2): 205–211. doi:10.1111/napa.12000. 
• Singer, Merrill and Weeks, Margaret 2005 The Hartford Model of AIDS Practice/Research. In Community Interventions and AIDS edited by Edison Trickett and Willo Pequegnat, pp. 153–175. Oxford, UK: Oxford University Press.
• Singer Merrill; Bulled Nicola (2013). "Interlocked Infections: The Health Burdens of Syndemics of Neglected Tropical Diseases". Annals of Anthropological Practice 36 (2): 326–344. doi:10.1111/napa.12007. 
• Solomon, T., Halkitis, P., Moeller, R., Siconolfi, D., Kiang, M., and Barton, S. 2011 Sex Parties among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: Attendance and Behavior. Journal of Urban Health[in press]
• Southgate Erica, Weatherall Day, Marr Anne, Carolyn Dolan, Kate (2005). "What's in a Virus? Folk Understandings of Hepatitis C Infection and Infectiousness among Injecting Drug users in Kings Cross, Sydney". International Journal for Equity in Health 4: 5. 
• Specter, Michael 2005 Higher Risk: Crystal Meth, the Internet, and dangerous Choices about AIDS. The New Yorker, May 23, pp. 39–45.
• Stall, Ron 2007 An Update on Syndemic Theory Among Urban Gay Men. Presented at the American Public Health Association meetings, Washington, D.C. Abstract #155854. Abstract available online at: http://apha.confex.com/apha/135am/techprogram/paper_155854.htm.
• Stall, Ron, Friedman, M.S., and Catania, J. 2007 Interacting Epidemics and Gay Men’s Health: A theory of Syndemic Production among Urban Gay Men. In Unequal Opportunity: Health Disparities Affecting Gay and Bisexual Men in the United States, Richard J. Wolitski, Ron Stall, and Ronald O. Valdiserri (Eds). Oxford: Oxford University Press.
• Stall, Ron, Friedman, M.S., Kurz, M. and Buttram, M.— 2012 Syndemic associations of HIV risk among sex-working MSM in Miami and Ft. Lauderdale, USA. Presented at the XIX International AIDS Conference, Washington, D.C. (MOPE328, Poster exhibit).
• Stall Ron; Mills Thomas; Williamson J.; Hart T. (2003). "Association of Co-occurring Psychosocial Health Problems and Increased Vulnerability to HIV/AIDS Among Urban men who have Sex with Men". American Journal of Public Health 93 (6): 939–942. doi:10.2105/ajph.93.6.939. 
• Stall, Ron and Mills, Thomas 2006 Health Disparities, Syndemics and Gay Men’s Health. Presented at the Center for Health Intervention and Prevention. University of Connecticut. Available online at: http://www.chip.uconn.edu/lec/Stall%20-%20Connecticut%20Talk.pdf.
• Stall, Ron and van Griensven, Frits 2005 New Directions in Research Regarding Prevention for Positive Individuals: Questions Raised by the Seropositive Urban Men's Intervention Trial. AIDS 19 Supplement 1: S123-S127.
• Stephens, Christianne V. 2008 "She was Weakly for a Long time and the Consumption Set" In Using Parish Records to Explore Disease Patterns and Causes of Death In a First Nations Community. Research in Anthropology and Linguistics (RAL-e) Monograph Series. Ann Herring, Judith Littleton, Julie Park and Tracy Farmer (eds.) No. 3 134-148.
• Stephens, Christianne V. 2009 Syndemics, Structural Violence and the Politics of Health: A Critical Biocultural Approach to the Study of Disease and Tuberculosis Mortality in a Parish Population at Walpole Island (1850-1885). In Proceedings of the 39th Annual Algonquian Conference. Vol. 39 581-613. Karl Hele, (ed). London: University of Western Ontario.
• Storholm E., Halkitis P., Siconolfi D., Moeller R. (2011). "Cigarette Smoking as Part of a Syndemic among Young Men Who Have Sex with Men Ages 13–29 in New York City". Journal of Urban Health 88: 663–676. doi:10.1007/s11524-011-9563-8. 
• Talman Anna; Bolton Susan; Walson Judd (2012). "Interactions Between HIV/AIDS and the Environment: Toward a Syndemic Framework". American Journal of Public Health 103 (2): 253–261. doi:10.2105/ajph.2012.300924. PMID 23237167. 
• Tezal Mine (2012). "Interaction between Chronic Inflammation and Oral HPV Infection in the Etiology of Head and Neck Cancers". International Journal of Otolaryngology 2012: 575242. doi:10.1155/2012/575242. 
• Tian Li-Guang; Wang Tian-ping; Lv Shan; Wang Feng-Feng; Guo Jian; Yin Xiao-Mei; Cai Yu-Chun; Dickey Mary et al. (2013). "HIV and intestinal parasite co-infections among a Chinese population: an immunological profile". Infectious Diseases of Poverty 2: 18. doi:10.1186/2049-9957-2-18. 
• Tieu Van; Koblin B (2009). "HIV, Alcohol, and Noninjection Drug Use". Current Opinion in HIV and AIDS 4 (4): 314–318. doi:10.1097/coh.0b013e32832aa902. 
• Tobian Aaron; Quinn Thomas (2009). "Herpes simplex virus type 2 and syphilis infections with HIV: An evolving synergy in transmission and prevention". Current Opinion in HIV and AIDS 4 (4): 294–299. doi:10.1097/coh.0b013e32832c1881. 
• Thuy T.; Shah N; Hoang Anh M.H; Nghia D.T.; Thom D.; Linh T.; Sy D.N.; Duong B.D. et al. (2007). "HIV-Associated TB in An Giang Province, Vietnam, 2001–2004: Epidemiology and TB Treatment Outcomes". PLoS ONE 2 (6): e507. doi:10.1371/journal.pone.0000507. 
• Van Lettow M.; Fawzi W.; Semba R. (2003). "Triple Trouble: The Role of Malnutrition in Tuberculosisand Human Immunodeficiency Virus Co-infection". Nutrition Reviews 61 (3): 81–90. doi:10.1301/nr.2003.marr.81-90. 
• van Zyl-Smitt Richard; Brunet Laurence; Madhukar Pai; Yew Wing-Wai (2010). "The Convergence of the Global Smoking, COPD, Tuberculosis, HIV, and Respiratory Infections Epidemics". Infectious Disease Clinics of North America 24: 693–703. doi:10.1016/j.idc.2010.04.012. 
• van Zyl-Smitt Richard; Madhukar Pai; Yew Wing-Wai; Leunig C.; Zumla E.; Bateman E.; Dheda L. (2010). "Global Lung Health. The Colliding Epidemics of Tuberculosis, Tobacco Smoking, HIV and COPD". European Respiratory Journal 35 (1): 27–33. doi:10.1183/09031936.00072909. PMID 20044459. 
• Ventura H.; Mehra M. (2004). "The Growing Burden of Health Failure: The "Syndemic" is Reaching Latin America". American Heart Journal 147 (3): 412–417. doi:10.1016/j.ahj.2003.10.009. 
• Vogenthaler Nicholas; Hadley Craig; Rodriguez Allan; Valverde Eduardo; Rio Carolos; Metsch Lisa (2010). "Depressive Symptoms and Food Insufficiency Among HIV-Infected Crack Users in Atlanta and Miami". AIDS and Behavior 15 (7): 1520–1526. doi:10.1007/s10461-010-9668-1. 
• Yu F.; Nehl E.; Zheng T.; He N.; Berg C.; Lemieux A.; Lin L.; Tran A. et al. (2013). "A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China". Drug and Alcohol Dependence 132: 265–270. doi:10.1016/j.drugalcdep.2013.02.016. PMID 23517682. 
• Walkup James; Blank Michael; Gonzalez Jeffrey; Safren Steven; Schwartz Rebecca; Brown Larry; Wilson Ira; Knowlton Amy et al. (2008). "The Impact of Mental Health and Substance Abuse Factors on HIV Prevention and Treatment". Journal of Acquired Immune Deficiency Syndrome 47 (1 Supplement): S15–S19. doi:10.1097/qai.0b013e3181605b26. 
• Wallace R. A (1988). "Synergism of Plagues". Environment Research 47: 1–33. doi:10.1016/s0013-9351(88)80018-5. PMID 3168963. 
• Wang C.; Yang C.; Chen H.; Chuang S.; Chong I.; Hwang J.; Huang M. (2008). "Impact of type 2 diabetes on manifestations and treatment outcome of pulmonary tuberculosis". Epidemiology and Infection 137 (2): 203–210. doi:10.1017/s0950268808000782. 
• Wasserheit J (1992). "Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases". Sexually Transmitted Disease 19: 61–77. doi:10.1097/00007435-199219020-00001. 
• Weaver Lesley Jo; Mendenhall Emily (2013). "Applying Syndemics and Chronicity: Interpretations from Studies of Poverty, Depression, and Diabetes". Medical Anthropology 33: 92–108. doi:10.1080/01459740.2013.808637. 
• Wim Vanden Berghe; Laga Marie Nöstlinger Christiana (2014). "Syndemic and Other Risk Factors for Unprotected Anal Intercourse Among an Online Sample of Belgian HIV Negative Men Who have Sex with Men". AIDS and Behavior 18: 50–58. doi:10.1007/s10461-013-0516-y. 
• Young Fiona; Critchley Julia; Johnstone Lucy; Unwin Nigel (2009). "A review of co-morbidity between infectious and chronic disease in Sub Saharan Africa: TB and Diabetes Mellitus, HIV and Metabolic Syndrome, and the impact of globalization". Globalization and Health 5: 9. doi:10.1186/1744-8603-5-9. 

External links

• https://web.archive.org/web/20060823101806/http://www.cdc.gov/syndemics/
• Merrill Singer (October 2008). "The Perfect Epidemiological Storm: food insecurity, HiV/aids and Poverty in southern africa". In Focus. Archived from the original on 2011-06-07. https://web.archive.org/web/20110607085043/http://www.aaanet.org/publications/upload/49-7-Merrill-Singer-In-Focus.pdf. 
• https://web.archive.org/web/20080308030643/http://www.cdc.gov/syndemics/pdfs/Encyclopedia.pdf
• "A Dynamic Simulation Model of Syndemics: Casual Structure, Assumptions, and Results". Centers for Disease Control and Prevention. April 2003. http://forio.com/simulation/syndemic2003/Syndemic2003pres.pdf.