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Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief (2019)

Chapter:Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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Proceedings of a Workshop


IN BRIEF

November 2019

Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV

Proceedings of a Workshop—in Brief

The syndemics model describes co-occurring epidemics that have a multiplicative effect on bodily systems through the adverse interaction of two or more diseases or health conditions (e.g., malnutrition), whose interactions with social conditions exacerbate both the prognosis and the burden of disease (e.g., through the weakening of human immune capacity, signaling systems of the body, or behavioral practices that are bound to health). In this model there are two layers of interaction—the way diseases interact with each other and the way diseases are promoted by the social conditions in which people are living (which may be mediated by environmental conditions). The model therefore considers the full range of biosocial and bio–bio interactions in mental and physical health outcomes, where physical trauma, mental health trauma, and damage to the immune system may cause damage to other bodily systems—as the dysfunction of one system causes others to suffer, with the deleterious consequence of worsening the disease burden.

The model also considers disease interactions at the levels of both the individual and the population—taking into account the way that diseases and health conditions are exacerbated by their clustering in a population. For example, poverty may result in overcrowding and overcrowding may increase the potential of exposure to disease. At the same time, lack of food in impoverished communities may contribute to undernutrition and a lack of micro- and macronutrients, whereas a lack of available healthy food may contribute to both overnutrition and obesity. Violence within a community introduces trauma and stress, both of which increase the impacts on the immune system and other bodily systems. When viewing these biosocial and disease–disease interactions holistically, it becomes evident that violence, with its impact on the immune and other bodily systems, can manifest as an underlying driver of multiple health conditions. And so, the syndemics model provides a lens for examining how deleterious health effects result from the interaction of human biology with epidemic interpersonal and self-directed violence.

The concept of a syndemic also offers a foundation for effective multilevel preventive and intervention strategies that address these global public health issues by moving beyond the traditional silos of focusing on one epidemic. Such multilevel strategies allow interventionists to address the biological synergies that are produced by comorbidities that reinforce each other.

At a 2-day public workshop on May 16–17, 2019, convened by the National Academies of Sciences, Engineering, and Medicine’s Forum on Global Violence Prevention, participants explored the following three syndemics/co-occurring epidemics:


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Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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  1. Opioid use disorder (OUD), violence, suicide, and mental health in the United States
  2. Adverse childhood experiences (ACEs) and childhood trauma; adult violence and victimization; and health outcomes from a global perspective
  3. Human immunodeficiency virus (HIV) and violence

The workshop explored opioid-, ACEs-, and HIV-related violence syndemics from the perspectives of (a) survivors, (b) researchers studying these interactions, (c) public health professionals engaged with affected communities and in the creation and implementation of prevention and intervention measures, and (d) policy makers who are seeking multilevel interventions to address the complexities of comorbidities that reinforce and exacerbate each other. Through keynote and panel presentations followed by facilitated discussions, participants examined the evidence base surrounding these syndemics and described areas for future research. They also reviewed existing and potential strategies aimed at addressing these interrelated epidemics as multidimensional disorders with overlapping etiologies located within specific social, temporal, and geographical contexts.

Introductory remarks by Heidi Kar, Education Development Center, and Jacquelyn Campbell, Johns Hopkins University, stressed the timeliness of this workshop, given the advancements in understanding common risk and protective factors among the epidemics under consideration, and in the context of increased attention to violence as a global public health issue.

THE SYNDEMIC MODEL

In their keynote presentation, medical anthropologist Merrill Singer, University of Connecticut, and Nicola Bulled, Worcester Polytechnic Institute, discussed the origin and application of the syndemic concept. Singer coined the term “syndemic” to explain high rates of HIV/acquired immunodeficiency syndroms (AIDS) and other infections among illegal drug users, whose immune and other bodily systems, he hypothesized, were weakened by the chronic social stresses of discrimination and violence. From this observation, he conceived a holistic model of synergistic interactions of epidemics within deleterious social conditions that create a self-reinforcing cycle. As mentioned, the syndemics model describes co-occurring epidemics that have a multiplicative effect on bodily systems through the adverse interactions of two or more diseases or health conditions, whose interactions with social conditions exacerbate both the prognosis and the burden of disease.

According to Bulled, the syndemic model has been widely adopted but often incompletely applied. The challenge, she explained, is to identify the most significant among multiple factors that promote clustered epidemics and to create cost-effective interventions that address those key factors, in order to have the greatest overall impact. She noted, as examples of such interventions, conditional cash transfer programs in Brazil and Mexico linked to improved school attendance as well as to improved nutrition and reduced diarrhea incidence among children, and syringe exchange programs that reduce exposure to a range of infectious diseases.

THE EPIDEMIOLOGY OF SYNDEMICS AND CO-OCCURRING EPIDEMICS

This session featured three pairs of speakers, with each pair addressing the same topic from the dual perspectives of lived experience and research. This juxtaposition—of personal accounts of crisis, recovery, and advocacy against data-driven analysis—was intended to weave together knowledge streams that are often separated.

OUD, Violence, Suicide, and Mental Health in the United States

Heriberto Sanchez, Boston Public Health Commission, opened the session with a powerful recounting of his experiences of violence during his fractured childhood, heroin use disorder, and incarceration. He then described how he emerged from these crises to work in outreach toward others walking the same path. Now a program manager for the Citywide Overdose Prevention Program for the Boston Public Health Commission—which Sanchez described as an organization that is within “the epicenter of . . . violence, substance use disorder, mental health, and homelessness”—he strives to engage with his community and with individuals as he educates others on safe drug use and offers council on treatment options.

Debra Houry, National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention (CDC), noted that more than 47,000 Americans died of opioid overdose in 2017. She noted that for each such death, an estimated 48 people have OUD, more than 230 misuse prescribed opioids, and 1,900 have been exposed to prescription opioids. Suicide rates and rates of medically treated suicide attempts and ideation have both increased in parallel with opioid-associated deaths. Increases in such “deaths of despair,” which also include alcohol-associated mortality, underlie the recent historic decline in life expectancy in the United States—the first since the 1918 influenza pandemic.

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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Houry described a range of demographic, social, and economic trends associated with rising deaths of despair that suggest both proximal risk factors (such as reduced economic opportunity, social disconnectedness, and physical and mental health problems) and long-term associations with ACEs. CDC-funded intervention programs that address these conditions include both community-based programs and policy-focused approaches that simultaneously target ACEs and OUD. In partnership with the Office of National Drug Control Policy, CDC supports efforts in 12 communities to create and implement innovative, evidence-based interventions to combat the opioid epidemic, and to then replicate and scale up interventions that prove to be efficacious. As an example, Houry highlighted an early intervention program currently under way in Martinsburg, Virginia. It features training for teachers and law enforcement personnel to address and prevent ACEs, as well as support services and activities for students whose ACEs put them at risk for OUD and suicide.

ACEs and Childhood Trauma, Adult Violence and Victimization, and Health Outcomes from a Global Perspective

Shannon Foley Martinez, Free Radicals Project, recounted her transition from trauma—including rape during her teens—to rage, as a member of a group of violent white supremacists. She escaped the ensuing cycle of violence and self-hatred with the support of a trusted adult. Now, in addition to working to prevent and disrupt violence-based extremism, she is the mother of seven children.

Emily Mendenhall, Georgetown University, underscored the importance of attending to stories like that of Martinez as a way of understanding contributors to human health and of informing effective public health interventions. As a medical anthropologist, Mendenhall has embraced the syndemic model in her work, which focuses on diabetes and its interaction with trauma, poverty, and HIV/AIDS. “Trauma from childhood, such as physical or sexual violence, that persists years later . . . cannot be dissociated from the chronic stress and inflammation within the body that are duly linked to diabetes,” she insisted. Mendenhall’s studies across a range of global communities reveal how complex socioeconomic and political processes on food systems influence rates of diabetes, a disease that—like HIV and mental illness—manifests and is experienced differently from place to place. Syndemic analysis and solutions are necessarily local, she argued, because locally specific conditions—as revealed in the stories of community members—explain why certain conditions cluster there. Mendenhall concluded her talk by listing a series of “upstream” preventive policies applicable to syndemics in general—including improved access to health care, housing, and livable wages. She also listed “downstream” solutions to reduce the impact of syndemics, such as establishing women’s collectives to support financial planning and education, community gardens, and forgiveness for medical bankruptcy. Similarly, she presented a broad range of clinical interventions (e.g., person-centered medical homes, incentives to health providers to keep patients healthy) and community-based interventions (e.g., improved access to mental health services, peer group counseling) from which tailored, localized approaches could be drawn.

HIV and Violence

In discussing her rape, South African Journalist Charlene Smith—who has written about that incident and her activism in its aftermath—said that her words applied to every community where poverty and harm are intertwined, including those in the United States. In 1999 and 2000, soon after being raped and, after great effort, obtaining prophylaxis against HIV, Smith spoke at global AIDS conferences, advocating post-exposure prophylaxis as standard treatment for survivors of rape. Based on her conviction that many rapists were survivors of violence as young men, she also volunteers in a transformative justice program for violent offenders. “We have got to try and understand what’s happening with the other party, including people who rape,” she insisted.

In her presentation on the intersection of gender inequalities, violence, and HIV in South Africa, Bulled offered evidence discrediting the notion that the inequitable burden of AIDS in Africa results from region-specific sexual behaviors, and she dismissed purely biomedical explanations of this inequity as incomplete. Instead, she proposed a syndemic model of intimate partner violence (IPV), based on the finding that such violence significantly increases the chances that a woman will acquire HIV. Bulled asserted that socially constructed gender inequality, wherein female dependence on men contributes to risky behaviors, underlies the violence–HIV syndemic in Africa. She noted that a systematic review of interventions to address violence and HIV in women identified only one that produced statistically significant effects on both violence and HIV-risk behaviors (e.g., increased condom use, greater communication about HIV). This intervention, the IMAGE/Women’s Co-Op, combined group-based gender transformative interventions with economic strengthening through both training and supplements for food, clothing, transportation, and child care.

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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Discussion

An hour of discussion followed the six presentations, during which workshop participants raised the following topics: existing and potential methods for measuring cumulative experiences of violence; distinctions among multiple, layered, and syndemic interventions; challenges and opportunities in identifying and addressing cultural norms that contribute to syndemics; and funding research on harm prevention beyond simply containing symptomatic behaviors.

FROM EXPERIENCE TO ADVOCACY, PREVENTION, AND INTERVENTION

In a panel moderated by writer and documentary filmmaker Maryanne Culpepper, the three speakers who had previously described their experiences of trauma and healing discussed how their past experiences inform their work in harm prevention and response.

Sanchez, a trainer in overdose prevention and naloxone administration for the Boston Public Health Commission, manages programs addressing substance use disorders, violence, homelessness, and community reentry following incarceration. He entered the field in 1993 as an outreach worker and attributes his initial success to his street reputation as someone who could be trusted. From that foundation, he persuaded peers to join a 21-day program for treatment of substance use disorder (which has since been defunded). Sanchez decried the loss of that crucial introductory residency, which he said gave people a chance “to start thinking about what got you there, and even the possibility that there might be hope.” The few alternatives to this lost program are chronically oversubscribed, he noted.

Smith is an award-winning journalist and author of 14 works of nonfiction and is the authorized biographer of Nelson Mandela. After experiencing rape in 1999, she involved herself in activism and counseling for rape survivors and rapists, many of whom fit both descriptions. Smith also described her advocacy for privacy for sexual harassment plaintiffs in her native South Africa, for rehabilitative rather than punitive justice, and for violence prevention focused on protecting children and emphasizing their rights.

Martinez, a program manager at the Free Radicals Project and an outreach prevention coordinator at Parallel Networks, was formerly a violent neo-Nazi who now uses her transformation story to inspire others. Acknowledging 10 years afterward that she had been raped was her first step in identifying the source of her destructive anger, gaining control over it, and refraining from passing it on through violence. By accepting—as she did—the basic principle that “hurt people hurt people,” she asserted that others could change how they think about violence, ask better questions about it, and find more effective solutions to it.

A key theme in the discussion following the panelists’ remarks was the association of gender norms with violence and the challenge of addressing anger, which, Jacquelyn Campbell noted, can be protective and useful for people in crisis but also can undermine healing from trauma. These considerations pointed toward the need for greater emotional support for young men, particularly within the context of restorative justice. Participants also discussed the notion of combining mental health services with other desired services (e.g., microlending) in order to avoid stigma. They explored ideas for establishing social networks that heal and for replacing those that harm, and confronted the need to counter what Martinez described as a manufactured hopelessness that keeps people in their place and preserves current power structures.

INTERVENTIONS, RESEARCH, DATA, AND EVIDENCE

Bulled moderated a panel of three researchers, each of whom described efforts to design and test interventions directed at diseases co-occurring with violence and other ACEs.

Magdalena Cerda, New York University, noted that while an estimated 40–90 percent of the population experiences a traumatic life event, people in poor neighborhoods are most likely to be among the 10–30 percent who go on to develop posttraumatic stress disorder (PTSD) as a result. She described a modeling study comparing two types of interventions intended to reduce PTSD in such communities: those that reduce violence versus those that address poverty through income supplementation. According to the model, reducing violence completely proved far less effective than a modest income supplementation scheme (of comparable cost to violence prevention) in preventing new cases of PTSD. Victoria Ngo, City University of New York, described National Institutes of Mental Health research on depression management conducted in Vietnam. The Livelihood Integration for Effective Depression Management (LIFE-DM) aimed to provide low-income women with effective skills for managing depression through group therapy that incorporated mood and stress management and skill building in problem solving and communication, and also to provide livelihood supports, including microfinance loans. A controlled study found that the LIFE-DM intervention package produced significant treatment effects for depression, as well as for income, self-efficacy, and social support. These gains persisted through scale-up and the program continues to expand, Ngo reported.

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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James Mercy, Division of Violence Prevention of CDC’s National Center for Injury Prevention Control, reviewed the population-level impacts of childhood adversity and violence on health and discussed the best available evidence for prevention. He noted that more than half of children worldwide, and nearly half of children in the United States experience some form of violence annually. ACEs, which include exposure to abuse, violence in the home, and other household challenges, are pervasive and have a dose–response relationship with increased risks of suicide, intravenous drug use, risky sexual behaviors such as infrequent condom use and early sexual initiation, as well as a broad range of other health outcomes such as heart disease and cancer. Mercy shared information on a range of strategies to prevent childhood adversity—such as strengthening economic supports, promoting healthy social norms, creating protective environments, teaching parenting skills, and engaging influential adults/peers—for which evidence-based programs and policies already exist. Mercy noted that these programs and policies form the basis for a range of possible interventions that need to be more broadly implemented and evaluated. A strong infrastructure for implementing and scaling up these interventions is currently lacking, but is feasible.

Discussion following the panelists’ presentations focused on a range of topics, including what research has revealed about the effects of various drug policies (including overdose Good Samaritan laws, marijuana legalization, and Medicaid expansion) on drug-related morbidity and mortality; the relationship of anger to PTSD; prospects for the funding of mental health interventions as part of U.S.-sponsored global HIV program; and appropriate implementation of generalized versus community-specific interventions. Summing up observations of the day’s proceedings, Hortensia Amaro, Florida International University, returned to the definition of syndemics, emphasizing the social factors central to this concept. Kar noted the recurring importance of connectedness to the health of individuals and communities.

CURRENT AND FUTURE PUBLIC HEALTH APPROACHES

In his keynote on the workshop’s second day, John Auerbach, Trust for America’s Health, used the example of Billy, an uninsured man receiving medical treatment for a back injury—but who is also at risk for multiple diseases of despair and for HIV—to illustrate how traditional practices of medicine and public health fail to address syndemic risk factors. Billy’s history, which would not be captured in a standard medical exam, reveals multiple social issues (poverty, job loss, lack of educational opportunities, disconnectedness, racism) and environmental risks (access to opioids and firearms, vulnerability to infectious diseases), all of which underlie a U.S. syndemic of drug- and alcohol-related disease, suicide, HIV, and homicide, Auerbach explained. He described how the demand for trauma-informed policies that integrate behavioral and physical health, and that address the social determinants of health, is being met through several small-scale interventions and pilot projects that could inform systemic change.

PREVENTION AND INTERVENTIONS

A panel of four speakers, moderated by Culpepper, presented diverse perspectives on prevention and interventions that mainly address violence, but which also involve HIV, PTSD, substance use disorder, and multiple social determinants of health.

Kyleanne Hunter, Brady Campaign, described an intervention that the foundation developed in order to change social norms on the perceived risk of keeping guns in the home. End Family Fire encourages safe gun storage in order to reduce known risks for suicide, homicide, and accidental death. It is currently being implemented as a pilot program focused on children through pediatricians and social workers.

Kayla Williams, Military, Veterans, and Society Program at the Center for a New American Security, discussed how military sexual trauma (MST) manifests itself in female service members. More highly correlated with PTSD than either combat trauma or sexual assault in the civilian setting, MST is a documented risk factor for suicide. She applauded recent policy changes, such as removing the security clearance requirement for service members who report seeking out mental health care in cases of MST, and she encouraged women veterans to make better use of evidence-based services offered by the U.S. Department of Veterans Affairs (VA).

Jamila K. Stockman, University of California, San Diego, presented her work on interventions for women living with HIV who are also affected by substance abuse, violence, trauma, and adverse mental health issues. She and her team created an enhanced peer navigation program intended to remove barriers to care for such women by (1) building skills to cope with syndemic-related affective distress; (2) teaching women interpersonal skills to activate social support networks (e.g., service providers, peers, friends, family) when faced with new or ongoing barriers; and (3) facilitating linkages with both HIV treatment and relevant ancillary service providers (e.g., for domestic violence, mental health, or substance use).

Suzanne Maman, University of North Carolina at Chapel Hill, provided snapshots of two intervention studies she undertook in Africa aimed at the intersection of HIV and violence. In Dar Es Salaam, she conducted an intervention that combined microfinance with peer-health leadership training for 15–19-year-old men. This approach proved particularly

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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effective at changing attitudes and norms around gender, and on increasing the use of HIV testing services, but it did not reduce the perpetration of violence, she reported. The second intervention, in South Africa, enrolled both HIV-positive and HIV-negative pregnant women in counseling on HIV testing, disclosure of their status, and violence. This produced risk reduction even among HIV-negative women, but no impact on the rates of disclosure or of violence.

Leading the facilitated discussion that followed panel presentations, Bulled summarized two contrasting approaches to syndemic interventions: one targets key interactions within a syndemic, resulting in preventive effects that spread through synergy; the other addresses the outcomes of syndemic relationships, and therefore the syndemic, as a whole. She prompted Williams, Stockman, and Maman to each identify one element of the relationships they had discussed as a target for powerful, far-reaching preventive interventions. Williams suggested that changing the gender culture of the military would ultimately make the VA a safe place for female veterans to get important preventive care. Stockman advocated targeting individuals identified as at risk for one syndemic condition (e.g., HIV) with broad-based interventions addressing other likely risks (e.g., suicide). Maman stressed the issues of power and control underlying women’s risk for vulnerability to both violence and HIV and noted that comprehensively addressing those issues would require multilevel interventions simultaneously directed at individuals, interpersonal networks, and communities. She acknowledged that testing such interventions in community-randomized trials would be expensive, and that efforts to date to obtain funding for such trials have failed.

Additional discussion focused primarily on the opportunities for and barriers to social change regarding major issues contributing to syndemics of violence, such as gun availability and gender inequity, through legislation or other regulatory measures.

POLICY RESPONSES

A panel of four speakers, moderated by Culpepper, presented diverse perspectives on the current state of policy, government responses, and stories of success in addressing syndemics.

Jennifer Solotaroff, World Bank, whose research focus is gender-based violence (GBV) in South Asia, described the role of child marriage and other old customs in perpetuating GBV and exacerbating its effects, which include risks for HIV transmission and for alcohol and drug use disorder. Preventing GBV in these settings will require shifting social norms over the long term, she said. Toward this goal, she described interventions designed to address the underlying perceived value of sons and daughters, and to provide for women’s education, a protective factor against child marriage. An example of proven early success in this effort, the Gender Equity Movement in Schools (GEMS), addresses sexual harassment through curricula for children as young as age 8 and engages teachers and other school staff as well. Solotaroff stressed that funding for implementing interventions for syndemics needs to include provision for ongoing, rigorous evaluation.

Avelardo Valdez, University of Southern California, described a pair of his ongoing National Institutes of Health (NIH)-funded longitudinal studies that began by following men and women who became involved with gangs in San Antonio, Texas, as teenagers. Among the cohort of 212 women, who are now aged 35 and older, Valdez stated that nearly four out of five had experienced IPV, and they had been in violent relationships for an average of about 9 years—against a backdrop of childhood trauma and other stressful life conditions and events, including substance use disorder and incarceration. Valdez endorsed policies such as limits to incarceration, medication-assisted treatment for OUD, family services, and job training, as the surest paths to reducing violence and its effects among this population.

Rita Nieves, Boston Public Health Commission, described its response to the opioid epidemic in an area within the city where OUDand co-occurring epidemics of homelessness, HIV, other infectious diseases, and mental illness are concentrated. The commission houses diverse services in one building located in this neighborhood, and in recent years has adopted policies that take a syndemic approach to addressing multiple health needs and reducing isolation. Nieves described how coalition-building through local government–community partnerships raised awareness of syndemic relationships and encouraged engagement in creating and implementing interventions. She added that, in collaboration with neighborhood groups, the commission opened an Engagement Center, which she described as “a welcoming and safe place for people struggling with all these issues . . . [to] escape the elements and engage in services.”

Ta’Adhmeeka Beamon, U.S. Office of the Global AIDS Coordinator and Health Diplomacy, discussed the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which is focused on HIV and violence prevention for adolescent girls and young women through Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS). PEPFAR launched the DREAMS partnership on World AIDS Day 2014 in response to the staggering rate of new HIV infections in adolescent girls and young women (AGYW) ages 15–24. PEPFAR has invested more than $800 million in 15 countries through DREAMS, reaching millions of AGYW and their communities in some of the highest HIV-burdened regions in the world. DREAMS provides a comprehensive, evidence-based package of core interventions to address the structural drivers that directly and indirectly make girls and young women vulnerable to HIV, including gender inequality, gender-based violence, and

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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limited access to education and economic opportunities. Recognizing that violence is a key driver of HIV acquisition in this population, DREAMS tackles violence through activities around community mobilization and changing norms, school and community-based HIV and violence prevention, parenting and caregiver programs, and post-violence care.

Leading the subsequent discussion, Bulled asked about the various challenges faced by panelists, including that of procuring funding for long-term interventions, particularly from bilateral partners. Solotaroff stated that public–private partnerships can provide the ongoing investment necessary to address syndemics. Asked by Bulled to identify interventions targeting essential relationships intended to address the syndemic as a whole, Valdez encouraged extending social services for hard-hit communities, and Nieves advocated for strengthening the continuum of substance use disorder treatment services so as to allow long-term care for multiple co-occurring conditions. In the South Asian context, Solotaroff stressed the need to raise the perceived value of the girl child.

CLOSING REMARKS

In the final session, Amaro and Kar distilled key messages, themes, and takeaways from the workshop. Amaro emphasized two perspectives on preventing syndemics involving violence: the merits of reducing the full spectrum of ACEs rather than focusing solely on violence, and the need to implement upstream, population-level measures that reduce the propensity for people to engage in violence. When viewed through a syndemic lens, violence and co-occurring epidemics are rooted in exacerbating social conditions that need to be identified and targeted in order for true prevention to occur, she concluded.

Collectively, Amaro and Kar described several major and recurring themes in the workshop presentations and discussions:

  • The phenomenon of epidemics of despair;
  • The importance of connectedness to health not only of individuals, but communities and populations;
  • The need to recognize the specific community and geographic contexts in which syndemics occur;
  • The limitations of condition-specific interventions and, by contrast, opportunities presented by midstream and upstream strategies, including legal regulatory changes, building multisector collaborations, income supplementation and housing support, changing social and gender norms, and the social structures they impose;
  • The importance of terminology in framing and addressing issues ranging from defining “syndemic,” to stigma-perpetuating terms for people who use violence (“perpetrators”), to the use of descriptors such as culture, custom, practice, and tradition;
  • The role of messaging in encouraging communities to generate and participate in interventions and public health approaches to violence prevention, and—with reference to messages that have succeeded (seatbelt use) and fallen short (gun safety)—how both emotion and legislation can advance such efforts;
  • The various contexts in which interventions can be conceived and applied to multilayered problems, as exemplified by a lack of connectedness at the level of the individual, the community, the nation, and the world; and
  • How the syndemic lens enables the identification of social factors underlying seemingly intractable endemic and epidemic violence.♦♦♦
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Liza Hamilton and Alison Mack as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

PLANNING COMMITTEE FOR INTERPERSONAL VIOLENCE SYNDEMICS AND CO-OCCURRING EPIDEMICS: PREVENTING VIOLENCE IN THE CONTEXT OF OPIOID MISUSE, SUICIDE, SOCIAL DISPARITIES, AND HIV: A WORKSHOP*

Hortensia Amaro(Co-Chair), Florida International University; Heidi Kar(Co-Chair), Education Development Center; Kenneth Feder, Johns Hopkins University; Robert Freeman, National Institutes of Health; Maeve McKean, City University of New York; James A. Mercy, Centers for Disease Control and Prevention; Corinne Peek-Asa, University of Iowa

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteurs and the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Hanni Marie Stoklosa, Brigham and Women’s Hospital. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS: This workshop was partially supported by Administration for Community Living; Becton, Dickinson & Co.; Catholic Health Initiatives; Centers for Disease Control and Prevention; Education Development Center; National Institutes of Health; Medical College of Wisconsin; and U.S. Department of Defense.

For additional information regarding the workshop, visit http://nationalacademies.org/hmd/Activities/Global/ViolenceForum.aspx

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal violence syndemics and co-occurring epidemics: Preventing violence in the context of opioid misuse, suicide, social disparities, and HIV: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/25634.

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Copyright 2019 by the National Academy of Sciences. All rights reserved.

Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
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Page2
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
×
Page3
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
×
Page4
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
×
Page5
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
×
Page6
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
×
Page7
Suggested Citation:"Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop - in Brief." National Academies of Sciences, Engineering, and Medicine. 2019. Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief. Washington, DC: The National Academies Press. doi: 10.17226/25634.
×
Page8
Interpersonal Violence Syndemics and Co-Occurring Epidemics: Preventing Violence in the Context of Opioid Misuse, Suicide, Social Disparities, and HIV: Proceedings of a Workshop—in Brief Get This Book
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The syndemics model is used to describe co-occurring epidemics that have a multiplicative effect on bodily systems through the adverse interaction of two or more diseases or health conditions. Additionally, in these situations, interactions with social conditions exacerbate both the prognosis and the burden of disease. There are two layers of interaction in this model—the way diseases interact with each other and the way diseases are promoted by the social conditions in which people are living. It is important to understand this concept in order to create and implement effective multilevel preventive and intervention strategies that address these global public health issues by moving beyond the traditional silos of focusing on one epidemic.

The National Academies of Sciences, Engineering, and Medicine convened a public workshop on May 16-17, 2019 to explore the syndemic model and three syndemics/co-occuring epidemics. This includes 1) opioid use disorder (OUD), violence, suicide, and mental health in the United States, 2) adverse childhood experiences (ACEs) and childhood trauma; adult violence and victimization; and health outcomes from a global perspective, and 3) human immunodeficiency virus (HIV) and violence. The workshop participants considered the perspectives of survivors, researchers studying these interactions, public health professionals engaged with affected communities and in the creation and implementation of prevention and intervention measures, and policy makers who are seeking multilevel interventions. This publication briefly summarizes the presentations and discussions from the workshop.

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