02853nas a2200217   4500000000100000008004100001260003700042100001100079700001500090700001200105700001300117700001300130700001500143700002000158245019200178856010900370300001300479490000600492520212300498022001402621       2022                            d  bPublic Library of Science (PLoS)1 aDean L1 aTheobald S1 aNallo G1 aBettee A1 aKollie K1 aTolhurst R1 aHall-Clifford R00aA syndemic born of war: Combining intersectionality and structural violence to explore the biosocial interactions of neglected tropical diseases, disability and mental distress in Liberia  uhttps://journals.plos.org/globalpublichealth/article/file?id=10.1371/journal.pgph.0000551&type=printable  ae00005510 v23 a<p>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.</p>
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