About

Nicola Bulled is a public health anthropologist who focuses on intervening in global health delivery to ensure that policies and practices are effective, culture-centered, and structurally responsive. She has collaborated with national, regional, and city governments, healthcare providers, community organizations, and community members across diverse locations including the United States, South Africa, Lesotho, Liberia, and Greece. Utilizing anthropological tools and skills, she examines factors contributing to disease and healthcare needs, providing multi-level perspectives on public health programming, service delivery, social conditions, and policies that contribute to vulnerabilities and poor health outcomes. Her specific research interests include HIV prevention, infectious diseases, disease prevention technologies, health communication, and community collaboration. Nicola Bulled holds a Ph.D. in Anthropology from the University of Connecticut and completed a two-year post-doctoral fellowship at the University of Virginia's Center for Global Health. Her professional experience includes roles as a program manager with Boston University’s Lesotho-Boston Health Alliance and the City of Boston’s Needle Exchange Program, as well as positions as an epidemiologist at the Massachusetts State Laboratory and research assistant roles at Boston Medical Center and the Colorado Department of Health. Her research has been supported by funding from the National Institutes of Health, National Science Foundation, and Fulbright IIE.

Research topics

• Sociology
• Medicine
• Political Science
• Geography
• Economic growth
• Development economics
• Virology
• Environmental health
• Bioinformatics
• Biology
• Pathology
• Socioeconomics
• Economics

Selected publications

• A qualitative study of the social and structural vulnerabilities of HIV and chronic disease syndemics in low-resource urban health facilities in South Africa

  Discover Public Health · 2026-03-30

  articleOpen access1st authorCorresponding

  Low- and middle-income countries are experiencing multiple epidemics, including HIV and chronic non-communicable diseases. These epidemics present a serious public health concern as they increase the demand for health services, negatively impact quality of life, and increase mortality. While efforts have been made to integrate care approaches within primary care, people living with HIV (PLWH) experiencing chronic comorbidities often face intersecting social and structural vulnerabilities that are not fully recognized. Given the robust evidence of converging epidemics of HIV and other chronic conditions, through the lens of syndemic theory, this study aimed to identify and examine the social and structural vulnerabilities driving syndemic disease within an urban population of PLWH in South Africa. This study applied a qualitative research design involving in-depth interviews with 13 PLWH and 14 healthcare providers in Johannesburg, South Africa collected between August and September 2024. Structural vulnerabilities (disrupted access to care, unemployment, migration) and social vulnerabilities (income, social support, violence, stigma) influence disease clusters through multiple pathways including chronic stress-induced physiological changes, reduced agency, and providers who lacked structural competency in recognizing how vulnerabilities impact disease pathogenesis and management. Direct consideration of these vulnerabilities with structural reform will meet the unique health needs and challenges of HIV and chronic disease syndemics. This will involve providers considering the social structures that undermine the capacities of patients and direct attention to social vulnerabilities through increased availability of resources both within and beyond healthcare facilities.

  PublisherOA PDFDOI

• Neighborhood deprivation and cardiometabolic risk factors in people living with HIV in urban South Africa

  Health & Place · 2026-01-01

  articleOpen access1st authorCorresponding

  Neighborhood deprivation has been shown in the United States to be associated with prevalence of chronic diseases, including cardiometabolic risk factors. The impact of neighborhood deprivation on people living with HIV in populations in sub-Saharan Africa is not well understood, and further, there are no studies exploring such associations with other comorbidities. Adult patients living with HIV (n = 22,253), who attended a public health clinic in nine ward areas of Johannesburg, South Africa, and completed an intake survey between 2022 and 2024, were included in the study. We used multi-level models to determine the association between the validated South African Index of Multiple Deprivation (SAIMD), a multi-dimensional tool that measures deprivation, with four cardiometabolic risk factors: body weight (kg), systolic blood pressure (SBP), elevated total cholesterol, and diabetes. In multivariable-adjusted models, neighborhood deprivation remained statistically significantly positively associated with SBP. The adjusted odds ratios (aORs) for indicators of poorly controlled SBP (>140 mmHg) revealed increases between the least and most deprived neighborhoods. In multivariable-adjusted models, higher levels of neighborhood deprivation were statistically significantly positively associated with indicators of cardiometabolic risk among adults living with HIV. These findings suggest that shared neighborhood level deprivation contributes to comorbid disease burden in PLWH. • Neighborhood deprivation is one of the most robust correlates of cardiometabolic disease in PLWH. • Cardiometabolic risk is positively associated with neighborhood deprivation in PLWH. • Deprived neighborhoods are associated with clusters of chronic health conditions. • Targeted community-level interventions can effectively address disease management.

  PublisherDOI

• An Update on Syndemics: Editorial Comments

  Tropical Medicine and Infectious Disease · 2025-07-02 · 1 citations

  editorialOpen access1st authorCorresponding

  The theory of syndemics hypothesizes that observed clusters of diseases in specific temporal and geographical contexts are the result of harmful socio-environmental conditions resulting in mutually enhancing deleterious consequences [...].

  PublisherOA PDFDOI

• Countries cannot cover the shortfall from US funding cuts

  The Lancet Global Health · 2025-11-13

  articleOpen access1st authorCorresponding
  PublisherDOI

• In Memoriam: Professor Merrill Charles Singer

  SSM - Mental Health · 2025-08-06

  articleOpen access1st authorCorresponding
  PublisherDOI

• An Update on Syndemics

  2025-01-01

  otherOpen access1st authorCorresponding

  The syndemics framework proposes that the co-occurrence of diseases within specific time periods and geographic regions is driven by adverse social and environmental conditions that exacerbate and reinforce poor health outcomes. Over the past quarter-century, this theoretical lens has significantly shaped health-related disciplines, offering critical insights into research, policy, and practice. This Special Issue seeks to spotlight emerging syndemic configurations of infectious diseases with the goal of informing more effective health policies and interventions. Much of the existing literature has focused on HIV-related syndemics; however, newer constellations of diseases—such as those involving COVID-19, Ebola, MPOX, dengue, mucormycosis, and neglected tropical diseases—are increasingly evident and merit scholarly attention. In addition, while pandemics increasingly cross borders and share underlying social determinants, the specific syndemic dynamics they generate are deeply shaped by local political, economic, cultural, and environmental factors. Accordingly, there is an urgent need for place-specific analyses that support tailored intervention strategies. In this Special Issue, authors were asked to address all three core elements of the syndemics framework: the biological interplay of diseases, the synergistic effects that emerge from their interaction, and the local social characteristics of affected populations that support disease clustering.

  Publisher

• Occupational Syndemics in Farmworkers in the Cape Winelands, South Africa

  Tropical Medicine and Infectious Disease · 2025-06-24 · 1 citations

  articleOpen access1st authorCorresponding

  Occupational exposures in the agricultural industry globally have been associated with heightened risk for several diseases. Reports written in South Africa in the last decade have raised awareness of the harsh occupational conditions and human rights abuses suffered by farmworker communities in the wine industry. Despite receiving "fair trade" labels upon reentry into the global market in the 1990s, the working conditions on wine farms in South Africa have remained unchanged and exploitative for centuries. Farmworkers remain dependent on substandard farm housing, have insecure land tenure rights, are exposed to toxic pesticides, are denied access to benefits and unionization, and endure long working hours in harsh environmental conditions with low pay. These occupational conditions are linked to interacting disease clusters: metabolic syndrome, problematic drinking, and communicable diseases including tuberculosis, HIV, and COVID-19. This milieu of interacting diseases with deleterious outcomes is an under-considered occupational syndemic that will likely worsen given both the lasting impacts of COVID-19 and more recent shifts in global public health funding.

  PublisherOA PDFDOI

• The occupational syndemics of miners in South Africa

  Discover Social Science and Health · 2024-08-16 · 3 citations

  articleOpen access1st authorCorresponding

  Occupational exposures in the large industrial mining sector contributed significantly to South Africa’s high excess death rate due to COVID-19. Historically poor work-protection oversight has perpetuated centuries of risky labor and living conditions within the industry, driving high levels of disease co-morbidities, and supporting enduring social vulnerabilities. In this paper, we offer a syndemic lens to consider the clustering of adversely interacting diseases among mineworkers in South Africa, drawing attention to the complex occupational health crisis and the need to move beyond simply reporting individual diseases or comorbidities among this population. The physically demanding and dangerous working conditions, the lack of adequate changes to crowded and unsanitary working and living situations, the failure to meet social and labor plan targets, the continued precarious nature of working contracts and mines, and the limited access to robust healthcare reflect the historically exploitative nature of industrial mining in South Africa that places miners at increased risk for various syndemics. This assessment of the adverse interactions of diseases and socioeconomic and political conditions highlights the need for focused research and more follow-through in comprehensive occupational reforms.

  PublisherOA PDFDOI

• Conceptualizing COVID-19 syndemics: A scoping review

  Journal of Multimorbidity and Comorbidity · 2024-01-01 · 9 citations

  reviewOpen access1st authorCorresponding

  Background: COVID-19's heavy toll on human health, and its concentration within specific at-risk groups including the socially vulnerable and individuals with comorbidities, has made it the focus of much syndemic discourse. Syndemic theory recognizes that social factors create the conditions that support the clustering of diseases and that these diseases interact in a manner that worsens health outcomes. Syndemics theory has helped to facilitate systems-level approaches to disease as a biosocial phenomenon and guide prevention and treatment efforts. Despite its recognized value, reviews of syndemics literature have noted frequent misuse of the concept limiting its potential in guiding appropriate interventions. Objective: To review how the term 'syndemic' is defined and applied within peer-reviewed literature in relation to COVID-19. Design: A scoping review of definitions within COVID-19 literature published between January 1, 2020 to May 15, 2023 was conducted. Searches took place across six databases: Academic Search Premier, CINAHL, JSTOR, MEDLINE/Pubmed, PsycINFO and Scopus. PRISMA-ScR guidelines were followed. Results: Content analysis revealed that COVID-19 has varied clustered configurations of communicable-non-communicable diseases and novel communicable disease interactions. Spatial analysis was presented as a new strategy to evidence syndemic arrangements. However, syndemics continue to be regarded as universal, with continued misunderstanding and misapplication of the concept. Conclusion: This review found that current applications of syndemics remain problematic. Recommendations are made on the design of syndemic studies. A syndemic framework offers an opportunity for systems-level thinking that considers the full complexity of human-disease interactions and is useful to inform future pandemic preparations and responses.

  PublisherOA PDFDOI

• Long Covid: A Syndemics Approach to Understanding and Response

  Applied Research in Quality of Life · 2024-02-03 · 2 citations

  articleSenior authorCorresponding
  PublisherDOI

Frequent coauthors

• Merrill Singer

  22 shared

• Rebecca Dillingham

  Center for Global Health

  6 shared

• Bayla Ostrach

  4 shared

• Inayat Ali

  3 shared

• Geoffrey Winegar

  2 shared

• Londolani Sitsula

  University of Venda

  2 shared

• Khuliso Ramatsisti

  University of Venda

  2 shared

• Rebecca Dillingham

  University of Virginia

  2 shared

Education

• Ph.D., Water and Health in Limpopo, South Africa: Water citizenship in rural South Africa; Syndemic of childhood enteric disease

  University of Virginia

  2015

• M.D.

  University of Virginia

Awards & honors

• The Lancet Series on syndemics in 2017
• Guest Associate Editor of a special issue on syndemics publi…
• Member of the review panel for the NIH/NIDDK/NHLBI, Addressi…
• Guest Speaker/Ad hoc Keynote Speaker for the 2019 National A…