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Quality Reproductive Care Depends on Understanding How Inequality Exacerbates Multiple Health Problems

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Boston University School of Medicine
Mountain Area Health Education Center

Unequal access to good quality reproductive health care is a leading cause of suffering and death worldwide. Disparities in reproductive care can lead to problems for millions of people – including poor birth outcomes and persistent health difficulties for those who cannot get abortions or face delays in obtaining them. My research reinforces the argument that addressing these inequalities in reproductive health must continue to be a global public health priority. 

But in order to effectively address problems in reproductive health, researchers, practitioners, and advocates need to understand that the damaging and unequal health effects are not due solely to physical or biological causes or, alternatively, solely to political, economic, or social circumstances. Both sets of factors interact with and reinforce one another. My colleague Merrill Singer developed the term “syndemics” to describe the worsened health consequences of two or more diseases interacting together in adverse social conditions. As is increasingly recognized by leaders in public health and primary care, disease interactions are often caused, exacerbated, or intensified by poverty, war, or gender-based violence. Thinking about challenges in reproductive health care in this way is crucial if we are to address inequality in this arena.

Biological and Social Interactions in Reproductive Health

In plain language, syndemics refers to the interaction of two or more diseases or biological conditions that – especially in unjust social conditions – worsen health difficulties and lead to increased suffering. This situation goes beyond just the simultaneous presence of two or more diseases or underlying health conditions. From a syndemics perspective, a person who happens to have more than one kind of illness is not just experiencing a particular sort of bad luck; this approach highlights the ways that overlapping and intersecting biological and social conditions make a person’s illness and suffering worse. Researchers have thus far identified such syndemic interactions for many people who suffer from biomedical diseases, mental illness, infections by pathogens, and behavioral health problems – and who also struggle with their health issues while living in a large variety of socially unequal conditions. Those conditions include poverty, war, colonial rule or its aftermath, incarceration, and migration to escape violence or economic deprivation, as well as stressful conditions of gender-based violence (including against queer or transgender people), stigma, and racial discrimination. More recently, this kind of research also focuses on the interactions of deprived or stressful conditions on persons experiencing non-disease situations such as pregnancy – as, for instance, when a pregnant woman faces stigma or damaging conditions that negatively affect how medical care is provided. Research to be published in late 2017 shows, for example, that social stigmatization interacts with pregnancy to undermine good health care for adolescents who become pregnant, or to increase risks for complications when women seek abortion in restrictive settings. Pregnancies in such circumstances can be regarded as less desirable, putting those affected at greater risk for inadequate or poor quality care and resulting negative health outcomes. The syndemic framework reveals that the most stigmatized reproductive experiences, such as abortion, adolescent childbearing, or the birth outcomes and parenting experiences of women of color, may make the people involved more susceptible to worsened suffering and unnecessarily adverse health outcomes. 

Along with other potentially marginalized populations, women are disproportionately affected by both socio-political and biological vulnerabilities. In many cultural and political-economic settings, women and girls are at greater risk for interactions between diseases and adverse or unequal social conditions. In one better-known example, a combination of biological and social vulnerabilities puts specifically ciswomen at special risk for contracting HIV, the virus that causes AIDS, and suffering unusually adverse effects from the interaction between this and other sexually transmitted infections. Poverty, among other factors, exposes women and girls to magnified risks for contracting the HIV virus and sexually transmitted infections and, at the same time, the financial cost of managing chronic health problems like AIDS can plunge women and girls deeper into poverty. To give further examples, pregnancy results in hormonal changes that increase risks for infectious disease transmission – while intimate partner violence has been shown to increase or escalate during pregnancy. In these ways, simply being a ciswoman – and a pregnant woman in particular – interacts with political and social systems of oppression to increase negative health risks and effects. Rather than regarding pregnancies, infections, and gender oppression as discrete, separate issues, a syndemic approach to reproductive health considers the intersection of these factors and the increased burden of negative outcomes.

Considering Medical and Social Issues Together Can Improve Health Care 

Traditional approaches to treating disease often proceed as if infections, chronic health problems, or social conditions occur in isolation from one another. But of course that is not true. As scholars and practitioners recognize that social conditions produce biological interactions, and comprehend that addressing biological factors alone does not change the structural conditions in which suffering occurs, they will be able to do much more to improve health care. Research, health policy advocacy, and health care delivery all stand to benefit from this perspective. As understandings of interactions accumulate, policymakers can improve prevention programs and practitioners can develop more holistic understandings of their patients’ lives, informing more realistic approaches to conditions that would otherwise have catastrophic consequences.

In the specific context of reproductive health, it is especially helpful to recognize the many typical ways in which health challenges interact with surrounding social circumstances – often marked by unequal deprivations or stresses. As long as structural inequalities disproportionately affect women, girls, and other marginalized people, effective health care will require recognition of the mutually reinforcing effects of health inequality and unequal life circumstances. Even a physiological event such as pregnancy is bound to play out differently and involve very different risks in unequal life circumstances. Good care requires recognizing this basic reality. 

Read more in Bayla Ostrach and Merrill Singer, “At Special Risk: Biopolitical Vulnerability and HIV/STI Syndemics among Women.” Health Sociology Review 21, no. 3 (2012): 258-271; Merrill Singer, Nicola Bulled, Bayla Ostrach, and Emily Mendenhall, "Syndemics and the Biosocial Conception of Health." The Lancet 389, no. 10072 (2017): 941-950; and Merrill Singer, Nicola Bulled, and Bayla Ostrach, “Syndemics and Human Health: Implications for Prevention and Intervention.” Annals of Anthropological Practice 36, no. 2 (2012): 205-211.