navigating health futures in a dynamic and democratic world

Syndemics

Prevention Network

Navigating Health Futures in a Dynamic and Democratic World

Bobby Milstein

Syndemics Prevention NetworkCenters for Disease Control and Prevention

[email protected]://www.cdc.gov/syndemics

University of Auckland School of Population HealthNew Zealand Ministry of Health

Auckland: September 12-14, 2007Wellington: September 19-21, 2007

Syndemics

Prevention Network

Topics for Today

• Principles of a Syndemic Orientation

• A Navigational View of Public Health Work

• Dealing with Dynamic Complexity

– Policy resistance

– Boundary critique

– Crafting high-leverage interventions

– Causal mapping and simulation modeling

– Building power

• Illustrations

– North Karelia Project

– CDC Diabesity Modeling

– Industrial Areas Foundation

• Questions and Discussion Throughout

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Prevention Network

• Common

• Diverse

• Interconnected

• Increasing

• Costly

• Debilitating

• Deadly

• Inequitably distributed

• Largely preventable

Chronic Conditions Here (and Everywhere) Are…

Defy quick fixes and require a sound system-wide strategy to protect health as well as other values

Syndemics

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“Public health is probably the most successful system of science and

technology combined, as well as social policy, that has ever been devised…It is, I think, a paradigmatic model for how you do concerned, humane, directed science.”

-- Richard Rhodes

Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002.

How to Meet the Challenge?

How is it directed?

How are innovators approaching the challenge of assuring more healthful and

equitable conditions?

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Innovation, Pragmatism, and the Promise of “What If…” Thinking

Shook J. The pragmatism cybrary. 2006. Available at <http://www.pragmatism.org/>.

Addams J. Democracy and social ethics. Urbana, IL: University of Illinois Press, 2002.

West C. The American evasion of philosophy: a genealogy of pragmatism. Madison, WI: University of Wisconsin Press, 1989.

"Grant an idea or belief to be true…what concrete difference will its being true make in anyone's actual life?

-- William James

Pragmatism• Begins with a response to a perplexity or injustice

in the world• Learning through action and reflection• Asks, “How does this work make a difference?”

Positivism • Begins with a theory about the world• Learning through observation and falsification• Asks, “Is this theory true?”

These are conceptual, methodological, and moral orientations, which shape how we think, how we act, how we learn, and what we value

Syndemics

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Epi·demic

• The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people

• Epidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic Diseases“

• Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work

Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.

Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htm

National Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/

Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873.

A representation of the cholera epidemic of the nineteenth century.Source: NIH

“The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.”

-- Gil Elliot

Syndemics

Prevention Network

Syn·demic

• The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena

• It acknowledges relationships and signals a commitment to studying population health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways

Confounding

Connecting*

Synergism

Syndemic

Events

System

Co-occurring

* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

Syndemics

Prevention Network

Time Series Models

Describe trends

Multivariate Stat Models

Identify historical trend drivers and correlates

Patterns

Structure

Events

Increasing:

• Depth of causal theory

• Robustness for longer-term projection

• Value for developing policy insights

• Degrees of uncertainty

Increasing:

• Depth of causal theory

• Robustness for longer-term projection

• Value for developing policy insights

• Degrees of uncertaintyDynamic Simulation Models

Anticipate new trends, learn about policy consequences,

and set justifiable goals

Tools for Policy Planning & Evaluation

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Seeing Syndemics

A syndemic orientation clarifies the dynamic and democratic character

of public health work

Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

• Studying innovations in public health work, with emphasis on transformations in concepts, methods, and moral orientations

• The word syndemic signals special concern for many kinds of relationships:

– mutually reinforcing health problems

– health status and living conditions

– synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens)

Health

LivingConditions

Power toAct

“Health Policy”

“Social Policy”

“Citizen-ship”

• It is one of a few approaches that explicitly includes within it our power to respond, along with an understanding of its changing pressures, constraints, and consequences

Syndemics

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Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004.

Working DefinitionSyndemic Orientation

A way of thinking about public health work that

focuses on connections among health-related

problems, considers those connections when

developing health policies, and aligns with other

avenues of social change to assure the

conditions in which all people can be healthy

Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense

Incorporates 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.

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Changing (and Accumulating) Views of Population Health

What Accounts for Poor Population Health?

• God’s will

• Humors, miasma, ether

• Poor living conditions, immorality (e.g., ?)

• Single disease, single cause (e.g., ?)

• Single disease, multiple causes (e.g., ?)

• Single cause, multiple diseases (e.g., ?)

• Multiple causes, multiple diseases (but no feedback dynamics) (e.g., ?)

• Dynamic feedback among afflictions, living conditions, and public strength (e.g., ?)

1880

1950

1960

1980

2000

1840

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006.

Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

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Exposes the Dynamic and Democratic Dimensions of Public Health Work

PUBLIC HEALTH WORK

InnovativeHealth

Ventures

UNDERSTANDING CHANGESystems Science

• What causes population health problems?

• How are efforts to protect the public’s health organized?

• How and when do health systems change (or resist change)?

SETTING DIRECTIONPublic Health

What are health leaderstrying to accomplish?

GOVERNING MOVEMENTSocial Navigation

Directing Change

Charting Progress

• Who does the work?• By what means?• According to whose values?

• How are conditions changing?• In which directions?

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• PossibleWhat may happen?

• PlausibleWhat could happen?

• ProbableWhat will likely happen?

• PreferableWhat do we want to have happen?

Bezold C, Hancock T. An overview of the health futures field. Geneva: WHO Health Futures Consultation; 1983 July 19-23.

“Most organizations plan around what is most likely. In so doing they reinforce what is, even though they want something very different.”

-- Clement Bezold

Seeing Beyond the Probable

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Re-Directing the Course of ChangeQuestions of Social Navigation

Prevalence of Diagnosed Diabetes, United States

0

10

20

30

40

1980 1990 2000 2010 2020 2030 2040 2050

Mill

ion

pe

op

le

HistoricalData

Markov Model Constants• Incidence rates (%/yr)• Death rates (%/yr)• Diagnosed fractions(Based on year 2000 data, per demographic segment)

Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164.

Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.

Markov Forecasting Model

Trend is not destiny!

How?

Why?

Where?

Who?

What?

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Reconnecting with a Voyaging Tradition

-- Polynesian Voyaging Society

“Nainoa Thompson, who studied under Mau Pialug, became the first Hawaiian navigator in over 500 years to guide a canoe over this traditional route without instruments.”

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A Navigational View of Public Health Work

Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.

Where we want to go?

How do we prepare to get there?

Where do you want your children to live?

Where you do want to live?

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"How do you know," I asked, "that in twenty years those

things that you consider special are still going to be here?"

At first they all raised their hands but when they really

digested the question every single one of them put their

hands down. In the end, there was not a single hand up.

No one could answer that question. It was the most

uncomfortable moment of silence that I can remember…

That was the defining moment for me. I recognized that I

have to participate in answering that question otherwise I

am not taking responsibility for the place I love and the

people I love.”

-- Nainoa Thompson


Syndemics

Prevention Network


"How do you know," I asked, "that in twenty years those

things that you consider special are still going to be here?"

At first they all raised their hands but when they really

digested the question every single one of them put their

hands down. In the end, there was not a single hand up.

No one could answer that question. It was the most

uncomfortable moment of silence that I can remember…

That was the defining moment for me. I recognized

that I have to participate in answering that question

otherwise I am not taking responsibility for the place I

love and the people I love.”

-- Nainoa Thompson


Syndemics

Prevention Network

Foundations of Directed Change

Science ConscienceConsciousness

Scire, to know

Facts EffectsSelf

Knowledge MoralityPower

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Chronic Conditions are Classic Examples of Dynamically Complex Problems

• Differences between short- and long-term consequences of an action

• Time delays (e.g., developmental period, time to detect, time to respond)

• Accumulations (e.g., prevalences, resources, attitudes)

• Behavioral feedback (e.g., reactions by various actors)

• Nonlinear causal relationships (e.g., threshold effects, saturation effects)

• Differences or inconsistencies in goals/values among stakeholders

Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458.

Syndemics

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Broad Dynamics of the Health Protection Enterprise

Prevalence of Vulnerability, Risk, or Disease

Time

HealthProtection

Efforts

-

B

Responsesto Growth

Resources &Resistance

-B

Obstacles

Broader Benefits& Supporters

R

ReinforcersPotentialThreats

To understand and govern health trajectories over time, our concepts and methods for policy analysis must encompass the

basic features of this dynamic and democratic system

To understand and govern health trajectories over time, our concepts and methods for policy analysis must encompass the

basic features of this dynamic and democratic system

Size of the Safer, Healthier

Population-

Prevalence of Vulnerability,

Risk, or Disease

B

Taking the Toll

0%

100%

R

Drivers ofGrowth

Values for Health & Equity

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What Do These Observations Having in Common?

Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514.

Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

• Low tar and low nicotine cigarettesLead to greater carcinogen intake

• Fad dietsProduce diet failure and weight gain

• Road building to ease congestion Attracts development, increases traffic, delays, pollution, and urban sprawl

• Antibiotic & pesticide useStimulate resistant strains

• Air-conditioning useRaises neighborhood heat

• Forest fire suppressionBuilds deadwood fueling larger, hotter, more dangerous fires

• War on drugs Raises price and attracts supply

• Suppressing dissent Inspires radicalization and extremism

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Policy Resistance is…

“The tendency for interventions to be delayed, diluted, or defeated

by the response of the system to the intervention itself.”

Meadows DH, Richardson J, Bruckmann G. Groping in the Dark: The First Decade of Global Modelling. Wiley: New York, 1985.

-- Meadows, Richardson & Bruckmann

Defining Keywords

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Systems Archetype

“Fixes that Fail”

Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994.

Fix

+

ProblemSymptom

-

UnintendedConsequence

+

Delay

+

-B

+R

Characteristic Behavior:

Better before Worse

Syndemics

Prevention Network

“Fixes that Fail” in Public Health Vocabulary

The Risk of Targeted Interventions

+

HealthProblem -

-

Exclusions

+

+

TargetedResponseB

Delay+R

What issues tend to be excluded?

Syndemics

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Some Categories of Exclusions

Conceptual

Social

Organizational

Political

Disarray

Disorientation

Disparity & Disconnection

Together, these forces may seriously undermine the effectiveness of health protection policy

Syndemics

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Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521.

How Many Triangles Do You See?

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Boundary Judgments(System of Reference)

Observations(Facts)

Evaluations(Values)

Ulrich W. Boundary critique. In: Daellenbach HG, Flood RL, editors. The Informed Student Guide to Management Science. London: Thomson; 2002. p. 41-42. <http://www.geocities.com/csh_home/downloads/ulrich_2002a.pdf>.

Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf

Boundary CritiqueCreating a new theory is not like destroying an old barn and erecting a skyscraper in its

place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment.

-- Albert Einstein

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The Weight of Boundary Judgments

Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.



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Implications for Policy Planning and Evaluation

Insights from the Overview Effect

• Maintain a particular analytic distance

• Not too close to the details of service delivery, but not too far as to miss the internal pressures of vulnerability, capacity, and health status

• Potential to explain temporal patterns (e.g., better before worse)

• Structure determines behavior

• Potential to avoid scapegoating


Richmond B. Systems thinking: critical thinking skills for the 1990s and beyond. System Dynamics Review 1993;9(2):113-134. Available at <http://www.clexchange.org/ftp/documents/whyk12sd/Y_1993-05STCriticalThinking.pdf>.

White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

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Seeking High-Leverage Policies

Wall painting in the Stanzino delle Matematiche in the Galleria degli Uffizi (Florence, Italy). Painted by Giulio Parigi in the years 1599-1600.

“Give me a firm place to stand and I will move the earth.”

-- Archimedes

Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.

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Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995.

National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.

Navigational VenturesFinland’s North Karelia Project

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Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995

Focusing the Intervention Policy

Policy A: Focus on High Risk Individuals

Policy B: Focus on Risk Conditions for All

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Broad Intervention PolicyNorth Karelia Project

Disease Burden

Disease Burden

Individual Effort

Public Work

Adapted from Puska P. North Karelia International Visitors’ Programme, 2003.

Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at <http://www.publicwork.org/1_2_philosophy.html>.

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Directing ChangeNorth Karelia Project

Selected Action Strategies

• Medical services, if necessary

• Newspaper coverage: articles, editorials, letters

• TV time: highly rated 30-45 minute shows (no PSAs)

• Housewives’ organization: cooking and dietary choices

• Opinion leaders: role models, support groups, public action

• Tax shifting: tobacco, butter, milk

• Economic Renewal– Decline of dairy – Rise of berry – Rise of vegetable oil and rapeseed oil– Rise of healthier breads, cheeses, sausages, etc

Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995.

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Transforming All Dimensionsof the System

Health

LivingConditions

Power toAct

Efforts to Fight Afflictions

Efforts to Improve Adverse Living Conditions

Efforts to Build Power

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Efforts to Fight Afflictions (design/deliver)

• Screening

• Education

• Risk reduction counseling

• Medical/pharmaceutical treatment

• Disease self-management


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Efforts to Improve Adverse Living Conditions (develop/promote)

• Tobacco legislation

• Food-labeling requirements

• Margarines and oils

• Low-fat milk

• Low-fat, low-salt, high-fiber bread

• Vegetable-containing sausage (with mushrooms)

• Berry farming and consumption

• Community competitions, morale, and social norms

• State welfare system (at the national, regional, sub-regional, and local levels)


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Health Professionals

• Physicians

• Health Educators

• Psychologists

• Epidemiologists

• Sociologists

• Hospital administrators

• Pharmaceutical manufacturers

• Nurses

• Rehabilitation therapists

Other Citizens

• Bakers

• Farmers

• Grocers

• Food scientists, manufacturers

• Restaurant owners

• Housewives

• Entertainers

• Entrepreneurs

• Journalists, media professionals

• Teachers

• School administrators

• Elected representatives

Building PowerNorth Karelia Project

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Charting ProgressNorth Karelia Project

Vartiainen E, Puska P, Pekkanen J, Toumilehto J, Jousilahti P. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. British Medical Journal 1994;309(6946):23-27.

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Mortality changes in North Karelia in 1970-1995 (per 100 000, 35-64 years, men, age adjusted)

0

200

400

600

800

1000

1200

1400

1600

All Causes All CVD CHD All Cancers Lung CancerCause of Death

Ra

te p

er

10

0,0

00

1979

1995

-49%

-68%-73%

-44%-71%

Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995.

National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Accessed May 30, 2004 at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.

Charting ProgressNorth Karelia Project

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Framing the Challenge of Chronic Illness

PERSONPeople living with

affliction

PLACEAreas with a

recurring problem of affliction

TIMEPeople

vulnerable to affliction

HealthStates &

Rates

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Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention

TargetedProtection

Society's HealthResponse

Demand forresponse

PublicWork

SaferHealthierPeople Becoming

vulnerable

Becoming saferand healthier

VulnerablePeople Becoming

afflicted

Afflictedwithout

Complications Developingcomplications

Afflicted withComplications

Dying fromcomplications

Health System Dynamics

Adverse LivingConditions

GeneralProtection

Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003.

Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004.

Gerberding JL. FY 2008 CDC Congressional Budget Hearing. Testimony before the Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, United States House of Representatives; Washington, DC; March 9, 2007.


“One major task that CDC is intending to address is balancing this portfolio of our health system so that there is much greater emphasis placed on health protection, on making sure that we invest the same kind of intense resources into keeping people

healthier or helping them return to a state of health and low vulnerability as we do to disease care and end of life care."

-- Julie Gerberding

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Balancing Two Major Areas of Emphasis

SaferHealthierPeople

VulnerablePeople

Afflictedwithout

ComplicationsAfflicted with

ComplicationsBecomingvulnerable


Becomingafflicted

Developingcomplications




Demand forresponse

GeneralProtection

TargetedProtection

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

Public Work

World of Providing…

• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…

Medical and Public Health Policy

MANAGEMENT OF DISEASES AND RISKS

World of Transforming…

• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…

By Strengthening…

• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.

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Seeing Conditions as Freedoms

• Adverse living conditions are circumstances that inhibit people's freedom to be safe and healthy and develop their full potential

• They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection)

• Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).

Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics

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Choice and Non-Choice

Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93.

“Choices are always made from among

alternatives presented by the social

environment, or by circumstances that were

themselves not chosen…When we recognize the

elements of non-choice in choice, we can escape

the contradiction between social causation and

individual responsibility and understand the

interactiveness of the two.”

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Understanding Health as Public Work


VulnerablePeople

Afflictedwithout

Complications

Afflicted withComplicationsBecoming

vulnerable


Becomingafflicted





Demand forresponse

GeneralProtection

TargetedProtection

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

-

Public Work-

Vulnerable andAfflicted People

Fraction of Adversity,Vulnerability and AfflictionBorne by Disadvantaged

Sub-Groups (Inequity)

-

PublicStrength

Citizen Involvementin Public Life

Social Division

Syndemics

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Evaluating Dynamic, Democratic Policies

How can we learn about the consequences of alternative policies in a system of this kind?


VulnerablePeople

Afflictedwithout

Complications

Afflicted withComplicationsBecoming

vulnerable


Becomingafflicted





Demand forresponse

GeneralProtection

TargetedProtection

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

-

Public Work-

Vulnerable andAfflicted People

Fraction of Adversity,Vulnerability and AfflictionBorne by Disadvantaged

Sub-Groups (Inequity)

PublicStrength

-

Citizen Involvementin Public Life

Social Division

Syndemics

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System Dynamics Was Developed to Address Problems Marked By Dynamic Complexity

Good at Capturing

• Differences between short- and long-term consequences of an action

• Time delays (e.g., incubation period, time to detect, time to respond)

• Accumulations (e.g., prevalences, resources, attitudes)

• Behavioral feedback (reactions by various actors)

• Nonlinear causal relationships (e.g., threshold effects, saturation effects)

• Differences or inconsistencies in goals/values among stakeholders



Origins • Jay Forrester, MIT, Industrial Dynamics,

1961 (“One of the seminal books of the last 20 years.”-- NY Times)

• Public policy applications starting late 1960s

• Population health applications starting mid-1970s

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Learning In and About Dynamic Systems

• Unknown structure • Dynamic complexity• Time delays• Impossible experiments

Real World

InformationFeedback

Decisions

MentalModels

Strategy, Structure,Decision Rules

• Selected• Missing• Delayed• Biased• Ambiguous

• Implementation• Game playing• Inconsistency• Short term

• Misperceptions• Unscientific• Biases• Defensiveness

• Inability to infer dynamics from

mental models

• Known structure • Controlled experiments• Enhanced learning

Virtual World

Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330.


Syndemics

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A Model Is…

An inexact representation of the real thing

They help us understand, explain, anticipate, and make decisions

“All models are wrong, some are useful.”

-- George Box

“All models are wrong, some are useful.”

-- George Box

Syndemics

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Selected CDC Projects Featuring System Dynamics Modeling

• Syndemics Mutually reinforcing afflictions

• Diabetes In an era of rising obesity

• ObesityLifecourse consequences of changes in caloric balance

• Infant HealthFetal and infant morbidity/mortality

• PolioReintroductions after eradication

• Heart Disease and StrokePreventing and managing multiple risks, in context

Milstein B, Homer J. Background on system dynamics simulation modeling, with a summary of major public health studies. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; February 1, 2005. <http://www2.cdc.gov/syndemics/pdfs/SD_for_PH.pdf>.

• Grantmaking ScenariosTiming and sequence of outside assistance

• Upstream-Downstream EffortBalancing disease treatment with prevention/protection

• Healthcare ReformRelationships among cost, quality, equity, and health status

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Simulations for Learning in Dynamic Systems

Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000.


Multi-stakeholder Dialogue

Dynamic Hypothesis (Causal Structure)

X Y

Plausible Futures (Policy Experiments)

Obese fraction of Adults (Ages 20-74)

0%

10%

20%

30%

40%

50%

1970 1980 1990 2000 2010 2020 2030 2040 2050

Fra

ctio

n o

f p

op

n 2

0-74

Syndemics

Prevention Network

Model Uses and Audiences

• Set Better Goals (Planners & Evaluators)

– Identify what is likely and what is plausible– Estimate intervention impact time profiles– Evaluate resource needs for meeting goals

• Support Better Action (Policymakers)

– Explore ways of combining policies for better results– Evaluate cost-effectiveness over extended time periods– Increase policymakers’ motivation to act differently

• Develop Better Theory and Estimates (Researchers)

– Integrate and reconcile diverse data sources– Identify causal mechanisms driving system behavior– Improve estimates of hard-to-measure or “hidden” variables

Syndemics

Prevention Network

CDC Diabetes System Modeling ProjectDiscovering Stock-Flow Dynamics Through Action Labs


Syndemics

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CDC Diabetes System Modeling Project

• Diabetes programs face tough challenges and questions

– With rapid growth in prevalence, is improved control good enough?

– Studies show primary prevention is possible, but how much impact in practice and at what cost?

– How best to balance interventions?

• Model developed with program planners, diabetes researchers, and epidemiologists

• Model-based “learning lab” workshops for planners—federal, state, and local


Done in conjunction with Sustainability Institute and the Center for Public Health Practice at Emory University

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Health Care & Public Health Agency Capacity

• Provider supply• Provider understanding, competence• Provider location• System integration• Cost of care• Insurance coverage

Population Flows

DiagnosedStage 1

Diabetics

Stage 2Diabetics

Progression ofDx S1 to S2

S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics

Diagnosis ofS1 diabetes

Progression ofUndx S1 to S2

GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk

UndiagnosedPrediabetic

DiagnosedPrediabetic

Diabetes onsetfrom Undx PreD

Diabetes onsetfrom Dx PreD

Diagnosis ofPrediabetes

Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

We Convened a Model-Scoping Group of 45 CDC professionals and epidemiologists in December 2003 to Explore the Full Range of Forces Driving Diabetes Behavior over Time

Personal Capacity

• Understanding• Motivation• Social support• Literacy• Physio-cognitive function• Life stages

Metabolic Stressors

• Nutrition• Physical activity• Stress

• Baseline Flows

Health Care Utilization

• Ability to use care (match of patients and providers, language, culture)• Openness to/fear of screening• Self-management, monitoring

• Percent of patients screened• Percent of people with diabetes under control

Civic Participation

• Social cohesion• Responsibility for others

Forces Outside the Community

• Macroeconomy, employment• Food supply• Advertising, media• National health care• Racism• Transportation policies• Voluntary health orgs• Professional assns• University programs• National coalitions

Local Living Conditions

• Availability of good/bad food• Availability of phys activity• Comm norms, culture (e.g., responses to racism, acculturation)• Safety• Income• Transportation• Housing• Education

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Inflow

Volume

Outflow

Developing

Burden ofDiabetes

Total Prevalence(people with diabetes)

Unhealthy Days(per person with

diabetes)

Costs(per person with diabetes)

People withDiagnosedDiabetes

Diagnosis Deaths

abPeople withPrediabetes

Developing

DiabetesOnset

c

d

People withNormal

Blood SugarLevels

PrediabetesOnset

Recovering fromPrediabetes

e

DiabetesManagement

DiabetesDetection

Obesity in theGeneral

Population

PrediabetesDetection &

Management

People withUndiagnosed

Diabetes

Deaths

Overview of Diabetes Stock-and-Flow Model

Syndemics

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Overview of Diabetes Stock-and-Flow Model

Inflow

Volume

Outflow

Developing

Burden ofDiabetes

Total Prevalence(people with diabetes)

Unhealthy Days(per person with

diabetes)

Costs(per person with diabetes)

People withDiagnosedDiabetes

Diagnosis Deaths

abPeople withPrediabetes

Developing

DiabetesOnset

c

d

People withNormal

Blood SugarLevels

PreDiabetesOnset

Recovering fromPreDiabetes

e

DiabetesManagement

DiabetesDetection

Obesity in theGeneral

Population

PrediabetesDetection &

Management


Diabetes

Deaths

Standard boundary

This larger view takes us beyond standard epidemiological models and most intervention programs

Syndemics

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Using Available Data to Ground the Model

Information Sources Data

U.S. Census

• Population growth and death rates• Fractions elderly, black, hispanic• Health insurance coverage

National Health Interview Survey• Diabetes prevalence• Diabetes detection

National Health and Nutrition Examination Survey• Prediabetes prevalence

• Obesity prevalence

Behavioral Risk Factor Surveillance System

• Eye exam and foot exam• Taking diabetes medications• Unhealthy days (HRQOL)

Professional Literature• Effects of risk factors and mgmt on onset, complications, and costs• Direct and indirect costs of diabetes

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One way we establish the model’s value is by looking at its ability to reproduce historical data

(2 variables out of 10 such comparisons)

Diagnosed diabetes per thousand total popn60

45

30

15

0

1980 1984 1988 1992 1996 2000 2004

Model

NHIS

Model

Diagnosed fraction of diabetes popn1

0.8

0.6

0.4

1980 1984 1988 1992 1996 2000 2004

NHANES IIINH

’99 -’00NH II

Homer J. Reference guide for the CDC Diabetes System Model. Atlanta, GA: Division of Diabetes Translation, Centers for Disease Control and Prevention; August, 2006. <<http://sustainer.org/pubs/diabetessystemreference.pdf>.

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Healthy People 2010 Diabetes Objectives:What Can We Accomplish?

-11%7.88.8 per 1,000

Reduce Diabetes–related Deaths Among Diagnosed

(5-6)

-38%2540 per 1,000

Reduce Prevalence of Diagnosed Diabetes

(5-3)

-29%2.53.5per 1,000

Reduce New Cases of Diabetes (5-2)

Increase Diabetes Diagnosis (5-4)

+18%80%68%

Percent Change

HP 2010 Target

Baseline

U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm

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A History of Missed Goals

Simulations have helped diabetes planners set more realistic goals.

Simulations have helped diabetes planners set more realistic goals.

Milstein B, Jones A, Homer J, Murphy D, Essien J, Seville D. Charting plausible futures for diabetes prevalence: A role for system dynamics simulation modeling. Preventing Chronic Disease July 2007. <http://www.cdc.gov/pcd/issues/2007/jul/06_0070>

20

30

40

50

60

1980 1985 1990 1995 2000 2005 2010

Time (Years)

Peo

ple

with

Dia

gnos

ed D

iabe

tes

per

1,00

0 P

opn

HP 2000 prevalence goal HP 2010

prevalence goal

Status quo(simulated)

+33%

-11%

-38%

Diagnosed Diabetes Prevalence per Thousand AdultsMeet HP2010 detection goal

Meet HP2010 onset goal

Surveillance data (NHIS)

+25%

Syndemics

Prevention Network

Connecting the ObjectivesPopulation Flows and Dynamic Accounting 101

It is impossible for any policy to reduce prevalence

38% by 2010!


Diabetes

People withDiagnosedDiabetes Dying from Diabetes

Complications

DiagnosedOnset

InitialOnset

PeoplewithoutDiabetes

As would stepped-up detection effort

Reduced death wouldadd further to prevalence

With a diagnosed onset flow of

1.1 mill/yr

And a death flow of 0.5 mill/yr

(4%/yr rate)

The targeted 29% reduction in diagnosed onset can only

slow the growth in prevalence

Milstein B, Jones A, Homer J, Murphy D, Essien J, Seville D. Charting plausible futures for diabetes prevalence: A role for system dynamics simulation modeling. Preventing Chronic Disease July 2007. <http://www.cdc.gov/pcd/issues/2007/jul/06_0070>

Syndemics

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Mon

thly

Unh

ealth

y D

ays

from

D

iabe

tes

per

Tho

usan

d

Policy Testing…and Reason for Hope

With a combination of improved control and aggressive primary prevention, growth in the burden of diabetes could

be limited for the next 10 years and for decades beyond.

With a combination of improved control and aggressive primary prevention, growth in the burden of diabetes could

be limited for the next 10 years and for decades beyond.

U.S. Morbidity from Diabetes Simulated 1980-2050

600

500

400

300

200

1980 1990 2000 2010 2020 2030 2040 2050

Combination

Primary prevention

Base

Control

Syndemics

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The Modeling Process is Having an Impact

• Budget for primary prevention was doubled– from meager to modest

• HP2010 prevalence goal has been modified– from a large reduction to no change (but still not an increase)

• Research, program, and policy staff are working more closely– Many new leaders emerging, but truly cross-functional

teams are still forming

• State health departments and their partners are now engaged– initial efforts in 13 states

Syndemics

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Syndemic Orientation

Expanding Public Health Science“Public health imagination involves using science to expand the

boundaries of what is possible.”

-- Michael Resnick

EpidemicOrientation

People inPlaces

BoundaryCritique

Governing Dynamics

Ca

us

al

Ma

pp

ing

Plausible Futures

DynamicModeling

Navigational Freedoms

De

mo

cra

tic

Pu

bli

c W

ork

Syndemics

Prevention Network

“Academics and pundits love to throw around the term ‘social capital’

and debate its nuances, but most of them couldn’t

organize a block party.”

-- Ed Chambers

Power Has to be Organized

Chambers ET, Cowan MA. Roots for radicals. New York: Continuum, 2003., p. 65.

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Growth of Citizen Leaders

“Almost everyone knows about the

explosion of the dot-coms…but millions

have still not heard the big story: the

worldwide explosion of dot-orgs.

More people today have the freedom,

time, wealth, health, exposure, social

mobility, and confidence to address

social problems in bold new ways.”

-- David Bornstein

Bornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004.

Number of Public Service GroupsRegistered with IRS

0

500,000

1,000,000

1989 1998

Nu

mb

er

Re

gis

tere

d

60%

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Prevention Network

Contrasting Strategies for Directing Social Change

Advocating Mobilizing Organizing

Definition• Pleading in another’s behalf

• Assembling or coordinating for a purpose

• Arranging systematically for harmonious functioning or united action

Form • A voice • A following • A working whole

Products • Special interests • Mass movements • Public work

In Practice

• Ad hoc• Diminishing #s over time• Weak accountability• Weak commitment to institutional development• Single, charismatic leader• Weak ties to values and self-interests

• Enduring• Increasing #s over time• Strong accountability• Strong commitment to institutional development• Many leaders in many networks• Strong ties to values and self-interests

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Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004. <http://www.industrialareasfoundation.org/>.

Living wage

Nehemiah Homes

Alliance Schools

Quest job training

Blight removal

Environmental cleanup

After school programs

Smaller high schools

Organizing PowerIAF Issue Campaigns

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• Broad-based, multi-issue orgs, built to win and built to last

• Power precedes programs

• Never do for others what they can do for themselves

• The world as it is vs. the world as it should be

• Act to get a specific reaction

• Public accountability begins with self-accountability

• No permanent allies, no permanent enemies

• Organize, disorganize, reorganize

Organizing PowerIAF Principles

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Organizing PowerIAF Organizing Activities

• Have relational meetings

• Find and train leaders

• Recruit institutions and allies

• Pay dues

• Do research (problems, power, interests)

• Act on winnable issues

• Evaluate every action

• Organize, disorganize, reorganize


Syndemics

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Revisiting our Hypothesis of Health System Dynamics

Incorporating Public vs. Professional Concern

Syndemics

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Health System DynamicsIncorporating Public vs. Professional Concern

Safer,Healthier

Population

VulnerablePopulation

Becomingvulnerable

Becoming nolonger vulnerable

Afflictedwithout

ComplicationsBecomingafflicted



Dying fromComplications



Syndemics

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Health System Dynamics Incorporating Public vs. Professional Concern

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Downstreamwork

Professionalconcern



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onprogression

-

Effect oncomplications

-

TertiaryPrevention

SecondaryPrevention

Downstreamwork

Professionalconcern



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout






-


-

TertiaryPrevention

SecondaryPrevention

Vulnerable andAfflicted Population

Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

Publicwork



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-

Effect on livingconditions

Effect onvulnerabilityreduction

GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

-

Publicwork



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-

Citizen Involvementand Organizing

SocialDivision

-

Publicwork



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-

Citizen Involvementand Organizing

SocialDivision

-

Publicwork

Institutional/organizationalemphasis on disease rather

than vulnerability

-



Syndemics

Prevention Network

SummaryWhy is it So Hard to Work Across the Whole System?

Initial Observations

• Upstream work requires more public concern, which is less a reaction to the prevalence of disease as to the spread of vulnerability and affliction that over many years threaten everybody (think of economic decline, inadequate education, unsafe housing, sprawl, racism, environmental decay, etc.)

• Long before upstream threats become widely apparent, money and other resources have focused downstream (where professional expertise and the weight of scientific evidence lie)

• Because of their role as providers of downstream services, health professionals do not respond to vulnerability and social inequity FOR ITS OWN SAKE, in the WAY that ordinary citizens often do

• Upstream health action involves broad-based organizing; it is political—but non-partisan—and cannot be done by professionals alone.

Syndemics

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“I can see how connected the

Māori are to their ancestry. And

because they are connected to

their past, I believe that it's much

easier for them to see the kind of

future they want to voyage to.”

-- Nainoa Thompson

Thompson N. The voyage of rediscovery: 1985-1987. Polynesian Voyaging Society, 2005. Available at <http://www.pvs-hawaii.com/newsletters/nl_rediscovery.htm>.

Voyage of RediscoveryHawaii – Aotearoa, 1985-1987

navigating health futures in a dynamic and democratic world

Documents

health problems

national institutes

term epidemic

navigating health futures

public workelliot

century book

cholera epidemic

century new york