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Introduction

Joining Scholarly Conversations

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When Merrill Singer coined the term syndemic in the early 1990s, he crystallized into a single word an important but often-neglected strand of thinking about how people actually experience health problems, particularly those who have been excluded from society’s full respect and protection. The following passage explains why he introduced the term.³

Commonly, violence, substance abuse, and AIDS have been described as concurrent epidemics among inner city populations. However, the term epidemic fails to adequately describe the true nature of the contemporary inner city health crisis, which is characterized by a set of closely interrelated, endemic and epidemic conditions, all of which are strongly influenced by a broader array of political-economic and social factors, including high rates of unemployment, poverty, homelessness and residential overcrowding, substandard nutrition, infrastructural deterioration and loss of quality housing stock, forced geographic mobility, family breakup and disruption of social support networks, youth gang formation, and health care inequality.

We have introduced the term “syndemic” to refer to the set of synergistic or intertwined and mutual enhancing health and social problems facing the urban poor. Violence, substance abuse, and AIDS, in this sense, are not concurrent in that they are not completely separable phenomena. Rather, they emerge in the lives of participants in our study as closely intertwined threads in the often tattered fabric of their daily lives. (Singer and Romero-Daza, 1997:1)

In the early phase of the HIV/AIDS epidemic, applied anthropologists like Singer teamed up with public health investigators in an urgent, though unfamiliar, effort to examine the local and cultural dimensions of vulnerability, risk, and prevention. In those nascent exchanges between anthropology and epidemiology (Hahn, 1995; Janes, Stall, Gifford, 1986; MacQueen, 2002; Trostle and Sommerfeld, 1996), Singer made explicit what had long been held as a basic principle by residents and observers of poor and minority neighborhoods: different types of health problems are frequently connected in ways that must not be overlooked.

With the Greek prefix syn, meaning together, the term within the public arena, where people come together to confront and craft a common world. Singer’s neologism points to the power of all relationships, raising questions about how different kinds of health problems affect each other. At the same time, it calls attention to the ways in which people and institutions relate to one another and to the physical places in which they exist. In its fullest sense, the word syndemic portrays health as a fragile, dynamic state that is imperiled when social and physical forces come together in harmful or dysfunctional ways. The word asks that all observers pay closer attention to the connections that have always existed but are often overlooked, unquestioned, or neglected in the conventional approach of epidemiology.

The notion of a syndemic does not challenge the legitimacy of epidemiology, which was invented to understand discrete, sporadically occurring problems and has proven itself to be an indispensable tool for guiding public health work. Instead, the idea invites us to develop a complementary science of relationships (Bammer, 2003; Emirbayer, 1997) that is capable of understanding and more effectively governing the dynamic forces that surround multiple health problems, along with the intricate organizational systems that we as a society create to anticipate and respond to them.

By advancing the notion that epidemics can and often do come together as syndemics, Singer resisted the tendency to divide different sorts of health threats into analytically or bureaucratically convenient categories. Instead, he deliberately expanded the boundary that most of us—especially health scientists—instinctively use when framing our thinking and action. He also used his neologism to question what sorts of facts and values ought to shape our work in protecting the public’s health. What Singer did not write about, however, was the degree to which his approach, grounded in critical medical anthropology (Singer, 2004), was connected to the process of “boundary critique” that had emerged almost a decade before as the methodological core of critical systems thinking (Ulrich, 1983, 2000, 2002).

To better appreciate the implications of Singer’s linguistic intervention, or of similar innovations that strive to transform our perceptions and performance of public health work, we must consider the conceptual orientation from which it springs. However, the quest to situate such innovations within a larger intellectual landscape draws us into a vast set of scholarly conversations about the conditions for health and the most productive ways of thinking and acting to assure them. One particular interpretation of Singer’s innovation recognizes its position and heritage within three broad but distinct spheres of scholarship (Figure 2).

Figure 2: Selected Fields and Sub-Fields Shaping Innovative Health Ventures

The public health sphere is the domain where society’s health-related goals are set. This sphere provides the context for learning what health leaders have set out to accomplish at different times, in different cultures, and from different points of view. Writings on public health history, health promotion, social epidemiology, and social ecology are among the most relevant strands of scholarship here.

The sphere of systems thinking and modeling aims to improve understanding in a world marked by dynamic complexity and animated by various forms of causal relationships (e.g., reinforcing and balancing feedback structures). This sphere provides a focus for questioning what processes cause health problems to emerge, how different health problems are related, what kinds of responses they evoke, and what it takes for health systems to change. Roles for analytic methods that focus explicitly on understanding causal relationships—like system dynamics mapping and simulation modeling—come to the forefront, as do philosophical considerations about the nature of causal reasoning itself.

Finally, the sphere of social navigation encompasses those aspects of thinking and action that address goal-directed movement, specifically the organization and governance of health-related conditions. This area deals with questions about who does the work to effect health-related change, by what means, against what forms of resistance, and in pursuit of which values. It also includes a reflexive dimension for discerning how health-related conditions are changing, for whom, and in what directions.

The subfield on Directing Change draws insights from broad-based democratic organizing ventures, with an emphasis on roles for citizen actors and critiques of public institutions, corporations, and professional practices. Likewise, the subfield on Charting Progress takes an expansive look at how we plan and evaluate public health work. By bringing the temporal dimension of population health dynamics to the forefront, it frames health improvement efforts in both a navigational and an evolutionary context. This sphere of inquiry also considers the epistemological prerequisites for recognizing and recording change within dynamic and democratic systems.

Taken together, these fields of inquiry highlight the dynamic and democratic character of health-related conditions and of our own health protection endeavors. These dimensions, in turn, sketch the outlines of a distinct conceptual reorientation that occurs when shifting from a problem-solving approach with a single, fixed problem at its center to the fluid, public craft of navigating health futures in an unstable and openly contested landscape.

For the purposes of this study, we drew boundaries around these particular fields of inquiry and labeled them in such a way as to highlight their relevance and interconnections. All of them share an essential navigational character in the processes of setting direction, understanding change, and governing movement. Each field is positioned to complement the others and their synthesis yields a transdisciplinary orientation for both studying and generating innovative public health ventures.

Figure 3 delineates several of the most prominent ideas that are hallmarks of each domain, based on a review of nearly 7,000 published references. This is not a causal diagram. It is a map of selected ideas and the scholarly conversations that emerge from them. The links indicate connections or possible connections that exist among the ideas, in some cases even where the relevant writers themselves have not noticed an association. The relationships depicted take several forms. One idea may follow from another, support it, or contradict it. The diagram’s intent is to examine pathways and consider how conversations change complexion based on the constellation of ideas that shape them. The authors listed within the parentheses and cited in the accompanying narrative convey salient perspectives, which may differ from one another. Red (bold) links are the most crucial ones for drawing together the three broad fields of inquiry.

Figure 3: Assuring the Conditions for Health: Selected Ideas Shaping Scholarly Conversations

Enlarge picture

Located on the far right of the diagram is the provocative idea, from physicist David Bohm, that in addition to the explicate order we perceive with our senses and measure with instruments, there is also an implicate order that explains the connectivity and wholeness exhibited throughout nature (Bohm, 1981). In many respects, our tendency to concentrate on either the explicate or the implicate order maps onto one of the primary distinctions affecting all public health thinking: the choice of an event-oriented view versus a relational view (Emirbayer, 1997). An event-oriented view is characterized by efforts to define specific problems and thereby devise narrowly targeted responses. It lends itself to the strict application of Cartesian positivist logic.

By contrast, a relational view resists focusing on any particular entities unto themselves and instead examines patterns of connection across layers of organization, searching for insight into the ties between a system’s structure and its observed behavior, often set within the context of a vast network of human relationships. This systems approach (von Bertalanffy, 1951; von Bertalanffy and LaViolette, 1981), with its willingness to engage the perplexity of daily life, resonates with the premises and practices of pragmatism (Addams, 2002; Dewey and Sidorsky, 1977; West, 1989), even though their vocabularies have remained largely distinct.

A notable exception can be found in the work of Werner Ulrich, who has written explicitly about the need to “pragmatize” critical systems thinking for professionals and citizens (Ulrich, 1998, 2000, 2003). Working in that populist vein, he has extended the ideas of pioneer systems thinkers like Churchman (Churchman, 1970) to stress the need for diverse stakeholders to engage in active boundary critique as they examine the various facts and values that are and are not included in a given intervention or inquiry (Ulrich, 1983, 2002).

The most complete synthesis of these approaches in contemporary systems practice appears in Midgley’s notion of systemic intervention (Midgley, 2000, 2006), which achieves a remarkable synergy by combining boundary critique with the power of methodological pluralism (Flood and Jackson, 1991; Mingers and Gill, 1997).

Moving further from right to left across Figure 3, the event-oriented and relational views each lead to correspondingly different notions of causality, with attendant differences in analytic methodologies. Despite modern critiques, epidemiology adheres largely to ideas ofvariable causality, in which one or more factors are assigned the role of a proximal or distal cause (Evans, 1976, 1993; Parkin, 1873; Susser, 1973, 1991, 2001). Alternatively, systems thinkers concentrate on the particular organization or configuration of variables at work in a problematic situation, pursuing the idea of design causality as their guide (Argyris, 1996; Dent, 2003; Richardson, 1991; Schon, 1983). These contrasting views of causal structure have also been translated into distinct mathematical forms, such as multi-level models (Diez-Roux, 2000) or system dynamics simulation models (Forrester, 1961; Homer and Oliva, 2001; Sterman, 2000), as just two of many possible examples.

A set of hybrid concepts, located in the middle right of the diagram, bridges the spheres of public health and systems thinking and modeling. These concepts include ideas about social ecology, which examines the reciprocal influence of individuals and their environments (Levins and Lopez, 1999; McLeroy, Bibeau, Steckler, et.al., 1988; Stokols, 1992, 1996; Stokols, Allen, Bellingham, 1996; Stokols, Grzywacz, McMahan, et.al., 2003), collaborative evaluation and community-based participatory research, which attempts to diversify participation and equalize power relationships in the conduct of program/policy evaluation or action research (Fawcett, Francisco, Hyra, et.al., 2000; Fawcett, 2002; Fawcett, Paine-Andrews, Francisco, et.al., 2001; Goodman, 1998, 2001a; Goodman, 2001b; Israel, Schulz, Parker, et.al., 1998; Minkler, 2000; Minkler and Wallerstein, 2003; Wallerstein, 1992; Wallerstein and Bernstein, 1994), social epidemiology, which strives to incorporate information on social determinants of health into theories of disease distribution (Berkman and Kawachi, 2000; Krieger, 2001a, 2001b; Syme, 1994; Syme, 1996; Syme, 2005), and health promotion, which attends to those conditions that sustain population health (Freudenberg, 1978, 1982; Freudenberg, Eng, Flay, et.al., 1995; Green, 1999; Green and Kreuter, 2004; Green, Richard, Potvin, 1996; Kreuter, 1992; Kreuter, 2003; Milio, 1981, 2001; Minkler, 1989, 1994; Puska, 1995). Although there are important differences among these traditions, they all proceed from an essentially relational view of the world and are devoted to exploring the interfaces between society and population health. For the most part, however, these orientations do not incorporate the sort of analytic formalisms that have become so prominent in the system sciences over the last 50 years (Midgley, 2003). In general, their commitment to a relational view tends to break down in the selection of formal analytic methods that are more consistent with conventional biomedicine and public health research (e.g., event-oriented, correlational methods like regression modeling).

One exception to this trend of mismatching concepts and methods can be found in the intricate mathematical models used by Rodrick and Deborah Wallace to track a synergism of plagues affecting New York City neighborhoods and suburbs since the 1970s (Wallace and Wallace, 1998; Wallace, 1988; Wallace and Wallace, 1997). Not coincidently, Singer drew heavily on the Wallaces’ research as a primary justification for his writing on syndemics (Baer, Singer, Susser, 2003; Singer, 1994, 1996; Singer and Clair, 2003; Singer and Romero-Daza, 1997; Singer and Snipes, 1992).

The cluster of relational approaches to public health work in the middle right of the diagram is also linked in important ways to the ideas of social navigation located on the left, but in this two-dimensional picture those connections are omitted.

Efforts to assure equitable conditions for health are widely understood to require an element of social action or planned intervention (Freudenberg, 1978; McKinlay, 1993), sometimes orchestrated to expose and challenge the practices of those perceived to be “disease promoters” (Freudenberg, 2005) or the “manufacturers of illness” (McKinlay, 1979). For that reason, leading practitioners and theorists have sought to incorporate concepts of power, politics, community organizing, and social movement in their analyses of public health work (Farmer, 2003; Fawcett, Paine-Andrews, Francisco, et.al., 1995; Israel, Checkoway, Schulz, et.al., 1994; Light, 1997; McKnight, 1978; Muntaner, 2002). In most cases, these ideas are shaped by a deeply-held desire to empower disenfranchised or oppressed groups and thereby approach a higher state of social justice (Rissel, 1994; Wallerstein, 1992; Wallerstein and Bernstein, 1994). The concern for achieving social justice is, in fact, so prominent that it has been argued to be a defining element of the field and of the public’s health itself (Beauchamp, 1976; Hofrichter, 2003; Krieger and Birn, 1998; Raphael, 2002; Ruger, 2004).

However, to appreciate the essential navigational character of the field one need not accept, a priori, that the struggle for social justice is the guiding ideal of public health politics. The mere facts of our plurality and agency in a constantly changing world make power and democratic organizing important dimensions of the work. According to the political scholar Joan Bondurant, “social and political theory have neglected the central question of means, and, therefore, the problem of inevitable conflict” (Bondurant, 1988:v.). Apart from pursuing abstract ends, like empowerment or social justice, we may properly consider and critique public health innovations within the larger sphere of efforts to build and exercise the power that we already possess.

Some democratic theorists (Alinsky, 1946, 1971; Chambers and Cowan, 2003; Freire, 2000; Gecan, 2002; Sirianni and Friedland, 2001a; Tarrow, 1998) carry this orientation still further by explaining that the work of governing social change goes beyond processes of collaboration to include an acknowledgment of our unique and sometimes conflicting interests, combined with a dedication to work across those differences as we negotiate and shape a common world.

Certain commentators have bristled at the notion of tying public health work so closely to the political sphere, fearing that it may undercut our claims of scientific credibility (Rothman, Adami, Trichopoulos, 1998). However, such criticisms generally confuse partisan politics, based on dogma and ideology (which are antithetical to scientific inquiry), with the robust traditions of nonpartisan politics (which often are the impetus for serious scientific practice and responsible evidence-based policy making) (Arendt, 1958; Crick, 1993; Fortun and Bernstein, 1998).

Also commonly overlooked is the nature of political action itself and its consistency (or inconsistency) with the aims of health protection. With that as a further consideration, we see that the inevitable conflicts over social direction among those with differing interests and aspirations must be conducted through the use of nonviolent action (Bondurant and Fisher, 1973; Gandhi and Fischer, 1983; King, 2002; Sharp, 1962, 1973a, 1990, 2005). The alternative is flatly inconsistent with the work of assuring equitable conditions for health.

Stepping back from the gritty details of how we wield power and govern change amidst our differences, we see that the entire process is aptly captured by the Polynesian concept of wayfinding (Evenari, Aginsky, Dorsky, et.al., 1999; Finney, 1976; Lewis, 1994; Polynesian Voyaging Society, 2002; Thompson, 2000a, 2005). The idea, as originally conceived, involves more than the physical task of navigating long-distance deep-sea voyages. It also encompasses the cultural values and practices that infuse decision-making at home (Thompson, 2000b). The idea combines the notion of navigating from place to place with the concepts of moving forward through time while transferring a continually evolving culture from one generation to the next. Just as each crew member on a canoe is ultimately responsible for its safe passage from port to port, so too are all members of society endowed with the opportunity—and the responsibility—to help govern the course of public affairs. As the biologist Garrett Hardin observed,

We cannot predict history but we can make it; and we can make evolution. More: we cannot avoid making evolution. Every reform deliberately instituted in the structure of society changes both history and the selective forces that affect evolution—though evolutionary change may be the farthest thing from our minds as reformers. We are not free to avoid producing evolution: we are only free to close our eyes to what we are doing” (quoted in Corning, 2000).

These ideas are not merely metaphorical; they also offer a precise nomenclature for describing the directed nature of change and our role as agents or navigators within it. Recent works on the concept of guided evolution and plausible futures echo many of these same sentiments (Banathy, 2000; Hancock and Bezold, 1994; Hawken, Ogilvy, Schwartz, 1982; Laszlo, 2001; Salk, 1973). However, much of that literature lacks the precision and sophistication that is possible using formal navigational science (Baker, 1981; Batschelet, 1981; Jammalamadaka and Sengupta, 2001) and intentional macroscopic orientations (Richmond, 1993; Rosnay, 1979; White, 1998).

There are also many practical benefits of seeing health-related social change as the product of our collective wayfinding. Specifically, it

• adds directionality to the other essential human conditions of natality, mortality, and plurality (Arendt, 1958);
• recognizes that each member of society, regardless of his or her nationality or legal status, is a system citizen in the literal sense of being an active participant in the systems of which he or she is a part (Meadows, 1991; Richmond, 2002; Richmond, 2003);
• elevates the stature and necessity for effective public work, which is defined as “sustained, visible, serious effort by a diverse mix of ordinary people that creates things of lasting civic or public significance” (Boyte, 2004b, 2005; Boyte and Kari, 1996a; Center for Democracy and Citizenship, 2001; Gardner, Csikszentmihalyi, Damon, 2001);
• underscores the value of cultural survival as the repository of time-tested wisdom (Colorado, 1992; Malama Hawaii, 2003; Polynesian Voyaging Society, 2002; Thompson, 2000b); and
• serves as a reminder of a basic but often neglected dimension of human freedoms (Sen, 1999; United Nations Development Programme, 2004): the freedom to move in directions other than those that our predecessors or contemporaries have established.

The phrase social navigation is my own invention (Milstein, 2002b, 2004b, 2004c; Milstein and Homer, 2004; Milstein and Seville, 2005), designed to combine the pragmatic, evolutionary perspective of wayfinding with the vast store of theory and experience about social movements (Etzioni, 1991a; Freeman and Johnson, 1999; Goodwin and Jasper, 2004; Morris and Mueller, 1992; Moyer, 2001; Sheller, 2001), the dynamics of conflict and nonviolent action (McAdam, Tarrow, Tilly, 2001; Powers, Vogele, Kruegler, et.al., 1997; Sharp, 1973a, 1990, 2005; Tarrow, 1998; York Zimmerman Inc. and WETA-TV, 2000), social entrepreneurship (Ashoka, 2004; Bornstein, 2004; Duhl, 2000); and broad-based democratic organizing (Chambers and Cowan, 2003; Cortes, 1993; Gecan, 2002; Industrial Areas Foundation, 1990; Osterman, 2002; Rogers, 1990; Warren, 2001; Wood, 2002). It also addresses the reflective and epistemiological aspects of these efforts to direct change under the complementary notion of charting progress.

In the context of public health literature, social navigation is closely aligned with the concept of community health governance (Lasker and Weiss, 2003), which grew out of the system-change orientation of the Turning Point Initiative (Hassmiller, 2002; Turning Point National Program Office, Turning Point Performance Management Collaborative, Public Health Foundation (U.S.), 2003). However, that particular model lacks some of the political texture and intergenerational features, as well as the potential mathematical formalism, of an explicit navigational framing.

The prospect of navigating toward healthier futures raises questions about our individual and collective capacities to counter those forces that might move society in dangerous or risky directions (Freudenberg, Eng, Flay, et.al., 1995). Building on the recent wellspring of ideas about community capacity and collective efficacy (Bowen, Martin, Mancini, et.al., 2000; Chaskin, 1999, 2001; Eng and Parker, 1994; Goodman, Speers, McLeroy, et.al., 1998; McKnight and Kretzmann, 1990; Norton, McLeroy, Burdine, et.al., 2002; Sampson, Raudenbush, Earls, 1997), I have sought to recast this notion in more outwardly democratic terms as public strength (Homer and Milstein, 2004; Milstein, 2003a).

This phrase permits two simultaneous strands of interpretation: one having to do with the power of citizens to direct the course of change toward a negotiated set of valued conditions, and the other emphasizing the vitality of the polis itself. It is precisely this latter aspect of preserving an open and active political sphere, where the potential for effective public work resides, that leads to our concern for vulnerability and inequity in adverse living conditions (Aday, 2001; Evans, Barer, Marmot, 1994; Kawachi, Subramanian, Almeida-Filho, 2002; Lamprecht and Sack, 2003; Marmot, 2004; Navarro, 1993, 2002; World Health Organization, 1986, 2005a)—not under the instrumental logic of social risk factors for disease, but rather as serious impairments of public health unto themselves (Buchanan, 2000).

Earlier, we observed that a new conversation about public health work had opened when Merrill Singer introduced the term syndemic. In light of the interconnected themes in Figure 3, it appears that we may already have articulated many useful principles and procedures to support and extend this direction in thinking. The conceptual move that allows us to see syndemics links the fields of public health, systems science, and social navigation. For that reason alone, it is worthy of our enthusiasm as well as our scrutiny. Seeing syndemics reveals novel lines of inquiry while reviving and reconnecting us to some of the most profound and long-standing conversations in the field.

For simplicity, we may refer to the entire conceptual outlook that approaches public health work in these dynamic and democratic terms as a syndemic orientation (Milstein, 2002b, 2002c, 2002d, 2004a, 2004b, 2004c).⁴ A closely aligned perspective was developed by sociologist Max Heirich in his book Rethinking Health Care to describe the conceptual, methodological, and ethical innovations that reworked the health landscape in America in the 20^th century (Heirich, 1999).

The real significance of a syndemic orientation, however, lies in the transformations that it might engender for our professional and scientific norms (Bammer, 2003; Fortun and Bernstein, 1998; Light, 1991, 1997; Lindblom, 1959; Schorr, 1997; Sigerist, 1943; Starr, 1982) and even more forcefully, in the meaning of public health work itself (Aday, 2005; Bambra, Fox, Scott-Samuel, 2005; Foege, 1987; McKinlay, 1979; McKinlay and Marceau, 2000a; Rosen, 1993; Szreter, 2002; Virchow and Rather, 1985; Walt, 1994; Wiesner, 1993). Both of these issues represent rich areas of scholarship and debate, to which this study contributes. The remainder of this report examines particular instances that illuminate and enrich our understanding of what a syndemic approach to public health work might entail.

Being less concerned with the idea of a syndemic when used as a noun (i.e., to name clusters of linked afflictions), we will concentrate instead on the nature of people’s thinking and action when they operate from a syndemic orientation. The study’s specific guiding questions are

• What kind of science lies beyond the boundaries of epidemiology, which focuses in name and in practice on the singular phenomenon of an epidemic?
• What concepts characterize a syndemic orientation?
• What methodologies support this perspective (scientifically, politically, morally)?
• What effects do these ways of thinking and acting have on individuals and in the world at large?

3. In the first decade after the word syndemic appeared in print, diffusion of the concept had not proceeded much further than its originator. In October 2001, the science citation index counted exactly 30 references to Singer’s most widely read article (Singer, 1994), and zero publications with the term syndemic in its title, abstract, or keywords. The one article to have featured the word in its title prior to 2001 was Singer’s 1996 report on connections among substance abuse, violence, and AIDS (SAVA) in the journal Free Inquiry in Creative Sociology. That journal, unfortunately, is not included in the science citation index, so it is impossible to track references to it. An expanded search encompassing publications not included in the index revealed several additional publications in which the concept was mentioned, all of which were authored by Singer himself (Singer, 1996, 1999, 2001; Singer and Romero-Daza, 1997). At least one other team of researchers did cite the 1996 SAVA paper, but they did not use the term syndemic in the text of their report (Valdez, Kaplan, Curtis, et.al., 1995). Moving beyond academic databases, Internet searches using a variety of search engines returned between 0 and 11 hits, all of which were links to Singer’s 1994 or 1996 article. This lack of an on-line presence provides a relatively clear starting point for tracking further diffusion in the years ahead.

Ideas about ecological and systems approaches had been circulating in the field, but there was no coordinated scholarship on the subject of syndemics per se. In November 2001, the CDC launched the Syndemics Prevention Network, which sparked widespread interest throughout the public health workforce and beyond (Centers for Disease Control and Prevention, 2001; Milstein, 2002b, 2005). Since then, recognition of the term has been growing and a widening conversation is now under way.

In November 2001, seven reports had used the word syndemic explicitly (Singer, 1994, 1996, 1998, 1999, 2001; Singer and Romero-Daza, 1997; Singer and Snipes, 1992). Just over six years later, in January 2008, approximately 200 such reports exist, with about 85% of them by authors other than Singer. Also, during that same time period, the number of Internet hits using the Google search engine grew from 0 to 2,820.

As of January 2008, approximately 625 colleagues representing over 400 organizations in 20 countries had joined the network, which continues to grow about 8% per month.

4. Strictly speaking, it might be more accurate to label the overall approach a “navigational orientation” or a “relational orientation.” But those descriptors tend to be less effective in capturing people’s initial imagination and in releasing their hold on outdated mental models (Doyle and Ford, 1998; Sterman, 2002). What is most important about the term syndemic is not the word itself, but the type of thinking that it engenders (Richmond, 2000), as well as the unique constellation of concepts and methods that it joins (Milstein, 2002a).

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Page last reviewed: January 30, 2008
Page last modified: January 30, 2008

Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion