Revisiting SAVA: Syndemic transition and the reconfiguration of disease and inequality

Syndemic theory emerged within medical anthropology to challenge nosological models that fragment illness into discrete diseases divorced from social context. Revisiting the original SAVA syndemic in Hartford, Connecticut-the empirical setting from which syndemic theory first developed-we argue that syndemics are historically dynamic formations that reconfigure over time. While recent scholarship has demonstrated the historical embeddedness and continuity of vulnerability, comparatively less attention has been paid to how syndemic configurations themselves are restructured within populations over time. Drawing on historical and contemporary epidemiologic evidence, we trace a period in which HIV, substance use, and violence were mutually reinforcing, followed by HIV-focused harm reduction and treatment efforts that reduced HIV's dominance without transforming the political-economic conditions that concentrated vulnerability. We conceptualize this patterned reordering as syndemic transition, a temporal extension of syndemic theory that foregrounds reconfiguration rather than resolution while retaining attention to the social production of disease.