85 VOL. 78, NO. 1, SPRING 2019 Human Organization, Vol. 78, No. 1, 2019 Copyright © 2019 by the Society for Applied Anthropology 0018-7259/19/010085-12 M. Amalia Pesantes is an Associate Researcher at the Centre of Excel- lence in Chronic Conditions (CRONICAS) at the Universidad Peruana Cayetano Heredia in Lima, Peru. Anne Tetens is a Master’s student in the Department of Anthropology at the University of Copenhaguen. They share frst author positions in this manuscript. Adela Del Valle is an Education Research Analyst and Evaluator at RTI International, and J. Jaime Miranda is the Director of the CRONICAS at the Universidad Peruana Cayetano Heredia in Lima, Peru. This study was supported by the Medical Research Council (United Kingdom) [MR/M007405/1]. “It is Not Easy Living with This Illness”: A Syndemic Approach to Medication Adherence and Lifestyle Change among Low-income Diabetes Patients in Lima, Peru M. Amalia Pesantes, Anne Tetens, Adela Del Valle, and J. Jaime Miranda This study analyzes the experiences of low-income people living with type 2 diabetes in Lima, Peru. We use a syndemic approach to describe and discuss their challenges in following physicians’ recommendations around medication adherence and dietary changes. We use the concept of “burden of treatment” to analyze patients’ stories and to understand the complexity of medication adherence and dietary changes in a middle-income country where the health system is still unprepared to provide chronic care. Analysis demonstrates that emotional, socioeconomic, and structural components play a role in patients’ capabilities for following the prescribed recommendations. We show that patient’s illness experiences are intimately linked to the capacity of the local health system to attend to their needs but are not always acknowledged when promoting self-management behaviors. Our study shows the relevance of a syndemics approach for understanding the interaction between individual and structural factors to make suggestions for improving the management of diabetes and the overall experience of chronicity. Key words: diabetes, Peru, chronic disease, adherence, syndemics Introduction M ost low- and middle-income countries (LMICs) are experiencing a change in the type of diseases that affect their populations. While formerly they were predominantly affected by communicable diseases (CDs), they are currently experiencing an overwhelming increase in the number of people affected by non-communicable diseases (NCDs), a change that especially affects the poor (Atun and et al. 2013; Mendenhall and Weaver 2014; Samb and et al. 2010). The WHO (2014) reports that in 2012, NCDs were responsible for 68 percent of the world’s 56 million deaths, and 75 percent of these occurred in LMICs. Overall, health care systems have somewhat successfully addressed CDs, and because of this, among many other contributing factors, people are now living longer—however, increasingly so with NCDs (Atun and et al. 2013). In other words, whereas people formerly survived diseases, they are now living with diseases, which translates into a change in the profle of mortality patterns, a change known as an “epidemiological transition” (Mendoza and Miranda 2017; Omran 1971). This ongoing transition in many LMICs towards chronicity brings with it a new understanding of illness as a burden on populations (Wahlberg and Rose 2015), entailing illness and treatment burdens felt both on an individual patient-level as well as on a national health care-level. Patients’ experiences with their illnesses are intimately linked to the capacity of the lo- cal health system to attend to their needs but are not always acknowledged when promoting self-management behaviors among those affected by chronic conditions. As formerly curable diseases have changed to incurable illnesses, patient-care is increasingly dependent on routine management by both physicians and patients themselves. Many NCDs, a group that brings together cardiovascular, diabetes, cancer, and chronic respiratory diseases, share common risk factors, such as unhealthy diet and physical inactivity (WHO 2017). For the patient living with a chronic illness, adherence to medications and lifestyle change is central for their well-being. Adherence, from a strictly clini- cal perspective, is defned as the extent to which a persons’ behavior (medication-taking and lifestyle practices) coincides with medical or health advice (McNabb 1997). Lifestyle is defned as long-term patterns of behavior in contrast to singular, isolated behaviors (Bruhn 1998), and the lifestyle