Left Coast Press Inc., 2012
Hardcover, 145 pages
In Syndemic Suffering, Emily Mendenhall explores the interactive relationship between myriad forms of violence, social suffering, and chronic disease, including diabetes and depression. Positioned between public health and critical medical anthropology, Mendenhall offers a comprehensive framework for understanding the “biology of poverty” in the United States (113). This book makes three primary contributions to medical anthropology and anthropology in/of public health: the book moves beyond a focus on diabetes’ cultural idioms by instead drawing attention to social distress; it develops a syndemic approach to the clustering of violence, immigration, diabetes, depression, and abuse that many Mexican immigrant women face throughout their lives; and it offers a deductive mixed methodology.
Political-economic Influences on Health
Mendenhall argues that by focusing on cultural idioms of distress, such as susto, ‘fright,’ and coraje, ‘rage,’ public health and anthropological research often omit critical attention to the political and economic factors that influence health and well-being. Collapsing political and economic factors into cultural idioms of distress, Mendehall argues, also may encourage biomedical practitioners to dismiss such idioms as only folk beliefs not “biomedical ‘fact’” (55). Mendenhall draws from cultural notions of kinship and personhood that inform Mexican idioms of distress to emphasize how social stressors “are often contributors to and consequences of social distress, depression, and diabetes” (56). By focusing on social stressors Mendehall illuminates the feedback loop of social suffering: diabetes and depression are caused by social suffering and social suffering is enhanced by the experience of chronic disease.
Mendenhall proposes a syndemic framework (Singer 1996; Singer & Clair 2003) for understanding “situations in which adverse social conditions, such as poverty and oppressive social relationships, stress a population, weaken its natural defenses, and expose it to a cluster of interacting diseases” (13). She identifies five core dimensions of health and well-being and names this syndemic VIDDA: Violence, Immigration, Depression, type II Diabetes, and Abuse. She argues that by evaluating these five dimensions as dynamically causal and individually experienced, her book “aims at demonstrating how increasing wealth disparity within our globalized, neoliberal world contributes to the profoundly disparate distribution of burdensome chronic diseases among the poor” (13). This framework, Mendenhall points out, can be extended beyond Mexican immigrant women in Chicago by elucidating sources of suffering. This framework should, however, be extended with attention to the particularities of historical and social factors among other populations. VIDDA bridges political economy of health and social epidemiological perspectives on embodiment by showing how “various dimensions of social, emotional, and biological stresses” are often “experienced as a single multifaceted force” (24). Drawing from these bodies of literatures, Mendenhall shows how environments, social inequalities, and emotional distress manifest in the body.
The book’s most innovative contribution is its mixed methodology. Narratives ground the qualitative and quantitative methods, following a grounded theory approach. While this prioritization of narrative may not seem new to medical anthropologists, as Mendehnall highlights, her deductive approach is novel in biomedical sciences, which tend to start with etic categories. For example, she notes that while diabetes is considered an “endpoint” or “outcome” in biomedical studies, she positions glycemic control as “one measure of a stressful life” (24). The innovation of this methodology is its ability to speak between disciplines, and perhaps between sub-disciplines of anthropology, connecting biological anthropologists, medical anthropologists, and anthropologists concerned with embodiment and inequality.
Each chapter illuminates the iterative methodology moving from narrative analysis to regression analysis of health outcomes followed by focused chapters on immigration and interactive disease pathways. In Chapter Two, Mendenhall draws from “classic” approaches to illness narratives in medical anthropology. She offers two wrenching and poignant narratives that demonstrate the “interconnectedness of structural, social, interpersonal, psychological and metabolic factors that contribute to health and well-being” (50). In Chapter Three, Mendenhall systematically catalogues forms of chronic stress and acute distress. This systematic cataloguing offers a breadth of considerations on causes of stress and is evocative of the complex synergies she describes throughout the book. Chapter Four specifically focuses on immigration stress, social integration, and social isolation. Exploring the Latino Paradox, Mendenhall shows how a focus on “culture” is not sufficient to understanding this syndemic but the breakdown of social networks and related feelings of marginalization are at “the root of poor health within this population” (26). Chapter Five illuminates the psychological, behavioral, and biological pathways that bi-directionally relate depression and diabetes. Each chapter speaks to the complex synergies between social, political, and economic factors that shape the egregious suffering evinced through the narratives that make this book cohere.
By rigorously exploring how macrosocial factors shape disease and suffering, Mendenhall’s book has the potential to reach well beyond the bookshelves of medical anthropologists. Indeed, it has the capacity to start new interdisciplinary conversations because of its complex methodology, theoretical grounding, and clearly argued prose. Mendenhall ends the book with a call for comprehensive and integrated healthcare for the poor. This, she notes, requires a change in biomedicine to recognize “the necessity to tend to the mind, the emotions, and to the fuller experience of social suffering to effectively tend to the body” (112). In the wake of the shutdown of the US government and the inauguration of the Affordable Healthcare Act, this book resonates deeply in the United States today. For these reasons, this book would make an excellent addition to undergraduate courses in medical anthropology, methods, and structural inequalities. In my experiences teaching structural violence and structural inequalities, students struggle to see how macrosocial forces influence individual bodies. The book makes links between the social and structural eminently clear. For graduate students, this book would make an excellent addition to research design and methods courses because it demonstrates how mixed methodologies are conceived and implemented. The multidisciplinary conversations animated in this book, through theory and methods, also make it valuable for scholars.
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, and Scott Clair. 2003 Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context. Medical Anthropology Quarterly 17(4):423-441.
Jessica Hardin is a PhD Candidate in the Department of Anthropology at Brandeis University. Her doctoral research focuses on evangelical Christian etiologies for metabolic disorders in Samoa. She is the co-editor (with Megan McCullough) of Reconstructing Obesity: The Meaning of Measures and The Measure of Meanings, which focuses on developing an anthropologically informed analytics for examining obesity.