A syndemic born of war: Combining intersectionality and structural violence to explore the biosocial interactions of neglected tropical diseases, disability and mental distress in Liberia

Abstract

The intersections between NTDs, disability, and mental ill-health are increasingly recognised globally. Chronic morbidity resultant from many NTDs, particularly those affecting the skin—including lymphatic filariasis (LF), leprosy, Buruli ulcer (BU) and onchocerciasis—is well known and largely documented from a medicalised perspective. However less is known about the complex biosocial interaction shaping interconnected morbidities. We apply syndemic theory to explain the biosocial relationship between NTDs and mental distress in the context of structural violence in Liberia. By advancing syndemic theory to include intersectional thought, it is apparent that structural violence becomes embodied in different ways through interacting multi-level (macro, meso and micro) processes. Through the use of in-depth qualitative methods, we explore the syndemic interaction of NTDs and mental distress from the vantage point of the most vulnerable and suggest that: 1) the post-conflict environment in Liberia predisposes people to the chronic effects of NTDs as well as other ‘generalised stressors’ as a consequence of ongoing structural violence; 2) people affected by NTDs are additionally exposed to stigma and discrimination that cause additional stressors and synergistically produce negative health outcomes in relation to NTDs and mental distress; and 3) the impact and experience of consequential syndemic suffering is shaped by intersecting axes of inequity such as gender and generation which are themselves created by unequal power distribution across multiple systems levels. Bringing together health systems discourse, which is focused on service integration and centred around disease control, with syndemic discourse that considers the biosocial context of disease interaction offers new approaches. We suggest that taking a syndemic-informed approach to care in the development of people-centred health systems is key to alleviating the burden of syndemic suffering associated with NTDs and mental distress currently experienced by vulnerable populations in resource-limited settings.

Mass drug administration for neglected tropical disease control and elimination: a systematic review of ethical reasons

“…Although MDA has proven its benefits in diminishing transmission rates of several PC-NTDs in many areas, over years of implementation, this measure cannot be expected solve all problems arising from these diseases. Relying solely on ‘magic bullet’ interventions, which are expected to solve multifactorial ‘syndemics’48 including social problems like stigma and poverty, can have unforeseen consequences. Multifactorial issues require multifaceted solutions, and the cost-effectiveness of drug distributions should not overshadow the need for alternative measures addressing socioecological determinants of ill health 49.…”

Unequal access to improved water and sanitation in a post-conflict context of Liberia: Evidence from the Demographic and Health Survey

“…For demographic factors, we find that male-headed households were less likely to have improved drinking water sources in comparison to their female-headed counterparts (OR = 0.86, p<0.001). In addition, older households (i.e., 40-49 and 50+) were less likely to have improved drinking water sources and sanitation facilities, compared to the youngest cohort (i.e., [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29]. Similarly, married, widowed, and divorced households were all less likely to have improved drinking water sources and sanitation facilities, compared to their single counterparts.…”

“…We fully adjusted for socioeconomic, geographical, and demographic factors in Model 3 and found that the patterns observed in Models 1 and 2 remained largely robust in terms of statistical significance. For demographic factors, it is interesting that older households -i.e., 40-49 (OR = 0.87, p<0.05) and 50+ (OR = 0.84, p<0.05)-were less likely to have improved drinking water sources, compared to the youngest cohort (i.e., [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29].…”

“…Similarly, an investigation into the 2018 gastroenteritis outbreak in Firestone District of Liberia found the cause to be elevated levels of E.coli and Shigella from drinking untreated water from creeks and hand pumps [20]. Consequently, many Liberians are at risk for neglected tropical diseases and their associated chronic morbidities because of poor infrastructure development, including inadequate water and sanitation infrastructure [21]. Elsewhere, studies have revealed that poor WASH accessibility heightens women and girls' vulnerability to domestic abuse and gender-based violence [22][23][24].…”

Participatory development of a community mental wellbeing support package for people affected by skin neglected tropical diseases in the Kasai province, Democratic Republic of Congo

“…6 Conflicts, political instability and weakened health and social systems often augment mental distress, which is compounded by stigma and discrimination among people affected by skin NTDs. 7 The DRC carries one of the highest burdens of leprosy within sub-Saharan Africa, with limited detailed information available regarding the prevalence of other endemic NTDs. 8 , 9 In 2022, 3032 new cases of leprosy were detected, of which 317 were already disabled at diagnosis.…”