syndemic thinking in the cdc futures initiative bobby milstein nccdphp strategy planning process...

Syndemic Thinking in the CDC Futures Initiative

Syndemic Thinking in the CDC Futures Initiative

Bobby Milstein NCCDPHP Strategy Planning Process

December 22, 2003

Bobby Milstein NCCDPHP Strategy Planning Process

December 22, 2003

CDC Futures Initiative Directions and Open Questions

CDC Futures Initiative Directions and Open Questions

What are the major challenges that stand in the way of greater effectiveness

For CDC as an organization?

For public health work as a societal endeavor?

Is the basic problem organizational disarray, which requires rearranging, or disorientation, which demands new approaches to thinking, problem framing, decision making, and organizing itself?

What are the major challenges that stand in the way of greater effectiveness

For CDC as an organization?

For public health work as a societal endeavor?

Is the basic problem organizational disarray, which requires rearranging, or disorientation, which demands new approaches to thinking, problem framing, decision making, and organizing itself?

What Does it Mean to Approach Public Health Work from a Syndemic Orientation?

What Does it Mean to Approach Public Health Work from a Syndemic Orientation?

Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. Accessed December 15, 2002 at <http://www.cdc.gov/syndemics>.

http://www.cdc.gov/syndemics

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Planned as a three-year study of innovations in health planning and evaluation

Member network includes

158 individuals

123 organizations

11 countries

Planned as a three-year study of innovations in health planning and evaluation

Member network includes

158 individuals

123 organizations

11 countries

http://broadcast.forio.com/sims/syndemic2003/

Phases of the Syndemics ProjectPhases of the Syndemics Project

Phase 1: explore trends, dilemmas, and innovations; develop working definitions; identify core concepts and methods

Phase 2: articulate the foundations of a syndemic orientation; work with others to use this perspective in transforming public health work at the CDC and beyond

Phase 1: explore trends, dilemmas, and innovations; develop working definitions; identify core concepts and methods

Phase 2: articulate the foundations of a syndemic orientation; work with others to use this perspective in transforming public health work at the CDC and beyond

CDC Futures Initiative Observations on Our Present Position

CDC Futures Initiative Observations on Our Present Position

Silos (organizational fragmentation)

Arrogance

Inefficient internal processes (molasses)

Focus on processes, not impact

Difficulty differentiating CDC work from other agencies

Persistent gap between science and practice (intrusion of politics?)

Disconnect between CDC work and public perception (niches of opportunity)

Window of opportunity for CDC leadership (on health system reform, informatics, chronic illness, and prevention broadly)

Silos (organizational fragmentation)

Arrogance

Inefficient internal processes (molasses)

Focus on processes, not impact

Difficulty differentiating CDC work from other agencies

Persistent gap between science and practice (intrusion of politics?)

Disconnect between CDC work and public perception (niches of opportunity)

Window of opportunity for CDC leadership (on health system reform, informatics, chronic illness, and prevention broadly)

CDC Futures Initiative Possible Stakes in the Ground

CDC Futures Initiative Possible Stakes in the Ground

View public as the primary customer

Lead emphasis on prevention (and protection?) throughout the

Health care delivery system (certainly)

Public health system (certainly)

Society (?)

Loosen fragmentation, but don’t lose specialization

Stimulate organizational evolution, not revolution (i.e., do not disrupt or dismantle existing infrastructure but make it grow in new, more balanced directions)

Use, but don’t become captured by the language of customer and products

View public as the primary customer

Lead emphasis on prevention (and protection?) throughout the

Health care delivery system (certainly)

Public health system (certainly)

Society (?)

Loosen fragmentation, but don’t lose specialization

Stimulate organizational evolution, not revolution (i.e., do not disrupt or dismantle existing infrastructure but make it grow in new, more balanced directions)

Use, but don’t become captured by the language of customer and products

CDC’s Shifting OrientationsCDC’s Shifting Orientations

MedicalOrientation

Customer ServiceOrientation

TransformationalOrientation

What is Transforming? • People’s health status• Conditions for health (threats)• Health response systems• CDC culture• Scientific methods• The way we think about and organize public health work

Elements of a syndemic orientation may help as we navigate these transitions

Elements of a syndemic orientation may help as we navigate these transitions

1946 1990 2000

Why Do We Do Public Health Work?Why Do We Do Public Health Work?

CDC Vision & Mission

Healthy people, in a healthy world, through prevention

To promote health and quality of life by preventing and controlling

disease, injury, and disability

CDC Vision & Mission

Healthy people, in a healthy world, through prevention

To promote health and quality of life by preventing and controlling

disease, injury, and disability

Institute of Medicine

The purpose of public health is to fulfill society’s interest in

assuring the conditions in which people can be healthy

Institute of Medicine

The purpose of public health is to fulfill society’s interest in

assuring the conditions in which people can be healthy

How we reconcile these two frames of reference will shape the possibilities for leading health system change

How we reconcile these two frames of reference will shape the possibilities for leading health system change

Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.

"In problem solving we seek to make something we do not like

go away. In creating, we seek to make what we truly care

about exist… We can get so caught up in reacting to problems

that it is easy to forget what we actually want. Organizations

must do both–resolve day-to-day problems and generate new

results. But if your primary role is to fix problems, individually

or collectively, rather than create something new and

meaningful, it's hard to maintain a sense of purpose, and..it's

difficult to harness the energy, passion, commitment, and

perseverance needed to thrive in challenging times."

"In problem solving we seek to make something we do not like

go away. In creating, we seek to make what we truly care

about exist… We can get so caught up in reacting to problems

that it is easy to forget what we actually want. Organizations

must do both–resolve day-to-day problems and generate new

results. But if your primary role is to fix problems, individually

or collectively, rather than create something new and

meaningful, it's hard to maintain a sense of purpose, and..it's

difficult to harness the energy, passion, commitment, and

perseverance needed to thrive in challenging times."

Solving Problems vs. Creating ValueSolving Problems vs. Creating Value

-- Peter Senge-- Peter Senge

Public Health Goals Are Expanding…and Accumulating

Public Health Goals Are Expanding…and Accumulating

Prevent disease and injury (~1850 -- present)

Promote health and development (1974 -- present)

Assure the conditions in which people can be healthy (1988 -- present)

Prevent disease and injury (~1850 -- present)

Promote health and development (1974 -- present)

Assure the conditions in which people can be healthy (1988 -- present)

“The perfection of means and confusion of goals characterizes our age.”

-- Albert Einstein

“The perfection of means and confusion of goals characterizes our age.”

-- Albert Einstein

What does it mean to organize science and society around the goal of assuring healthful conditions?

What does it mean to organize science and society around the goal of assuring healthful conditions?

Plan for TodayPlan for Today

Core ideas leading to a syndemic orientation

Health system dynamics

Health Systems Workgroup report (Figure 1)

Working toward a more balanced health system

Living conditions and the role of individual behavior

Importance of simulation modeling

Progress in systems modeling (if we have time)

Steps for putting maps in motion

Examples from three on-going modeling projects

Core ideas leading to a syndemic orientation

Health system dynamics

Health Systems Workgroup report (Figure 1)

Working toward a more balanced health system

Living conditions and the role of individual behavior

Importance of simulation modeling

Progress in systems modeling (if we have time)

Steps for putting maps in motion

Examples from three on-going modeling projects

Seeing SyndemicsSeeing Syndemics“You think you understand two because you understand one and

one. But you must also understand ‘and’.”

-- Sufi Saying

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

-- Sufi Saying

The word syndemic signals a special concern for relationships

Mutually reinforcing character of health problems

Connections between health status and living conditions

Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)

The word syndemic signals a special concern for relationships

Mutually reinforcing character of health problems

Connections between health status and living conditions

Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)

Ideas About InteractionIdeas About Interaction

Confounding

Connecting*

Synergism

Syndemic

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

Events

Systems

Co-occurring

Placing Health in a Wider Set of Relationships

Placing Health in a Wider Set of Relationships

Health

LivingConditions

Capacity toAct

A syndemic orientation is one of a few approaches that includes within it our power to respond

A syndemic orientation is one of a few approaches that includes within it our power to respond

Vision Element Main Task

Healthy People Improve health

Healthy World Enhance living conditions

Through Prevention Strengthen capacity

(public work for health)

CDC’s Vision for the 21st Century

Healthy People, in a Healthy World--Through Prevention

CDC’s Vision for the 21st Century

Healthy People, in a Healthy World--Through Prevention

Working Across Multiple ScalesWorking Across Multiple Scales

Goals People Places

Part Prevent disease

and injury People with affliction Neighborhoods

Whole Promote health and

development

Sub-groups with greater burden of affliction

Regions

Greater Whole

Assure conditions in which people can be healthy

Society with a recurring problem of inequitable burden

Planet

Innovations in Public Health WorkInnovations in Public Health WorkSteps in Public Health Problem Solving Trends and Emerging Priorities

Define the problem

Eliminate health disparities

Avoid activity limitation

Promote life satisfaction

Increase healthy days

Determine the cause

Social determinants of health

Income inequality

Eroding social capital

Unhealthy built environment

Adverse childhood experiences

Develop and test interventions

Comprehensive community initiatives

Ecological perspectives

Inter-sector collaboration

Health impact assessments

Implement programs and policies

Policy interventions

Community and systems change

Adaptation to local context

And scores more….And scores more….

Public health work is becoming more…

Inter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control

Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability

Questioning (evaluative, reflexive, practical)Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends

Public health work is becoming more…

Inter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control

Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability

Questioning (evaluative, reflexive, practical)Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends

Innovations Point to the Emergence of a Syndemic Orientation

Innovations Point to the Emergence of a Syndemic Orientation

Many other orientations rely on disconnected, singular, and unthinking approaches where means and ends have very different qualities (e.g., security by means of war)

Many other orientations rely on disconnected, singular, and unthinking approaches where means and ends have very different qualities (e.g., security by means of war)

A Complementary Science of Relationships

A Complementary Science of Relationships

Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a System that Protects the Public’s HealthDynamic interaction among multiple problems, problem solvers, and responses

Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a System that Protects the Public’s HealthDynamic interaction among multiple problems, problem solvers, and responses

Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation

System Dynamics

SocialNavigation

POLICYDEVELOPMENT

ASSESSMENT

ASSURANCE

NetworkAnalysis

CategoricalOrientationSyndemic

Orientation

Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation

System Dynamics

SocialNavigation

POLICYDEVELOPMENT

ASSESSMENT

ASSURANCE

NetworkAnalysis

CategoricalOrientationSyndemic

Orientation

Techniques • Causal diagramming• Storytelling, scenario-based planning• Game-based learning• Simulation experiments• Health impact assessment

Techniques • Leadership/institutional development• Power and interest mapping• Broad-based, multi-issue organizing• Action planning• Public work• Flow charting (logic mapping)• Journey mapping• Navigational statistics

Techniques • Problem naming• Network analysis• Time-trend analysis• Summary measures

The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people

Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“

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

The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people

Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes 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.

“Public death was first recognized as a matter of civilized

concern in the nineteenth century, when some public health

workers decided that untimely death was a question

between men and society, not between men and God. Infant

mortality and endemic disease became matters of social

responsibility. Since then, and for that reason, millions of

lives have been saved….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.

“Public death was first recognized as a matter of civilized

concern in the nineteenth century, when some public health

workers decided that untimely death was a question

between men and society, not between men and God. Infant

mortality and endemic disease became matters of social

responsibility. Since then, and for that reason, millions of

lives have been saved….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.

Public Health Began as Public WorkPublic Health Began as Public Work

-- Gil Elliot-- Gil Elliot

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor community health?

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor community health?

God’s will

Humors, miasma, ether

Poor living conditions, immorality (sanitation)

Single disease, single cause (germ theory)

Single disease, multiple causes (heart disease)

Single cause, multiple diseases (tobacco)

Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)

Dynamic feedback among afflictions, living conditions, and response capacity (syndemic)

God’s will

Humors, miasma, ether

Poor living conditions, immorality (sanitation)

Single disease, single cause (germ theory)

Single disease, multiple causes (heart disease)

Single cause, multiple diseases (tobacco)

Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)

Dynamic feedback among afflictions, living conditions, and response capacity (syndemic)

1880

1950

1960

1980

2000

1840

Focused Efforts to Prevent and Control Diseases Have Led to Major Achievements

Focused Efforts to Prevent and Control Diseases Have Led to Major Achievements

600

500

400

200

100

501950 1960 1970 1980 1990 1995

Rate if trend continued

Peak Rate

Actual Rate

Age-a

dju

sted D

eath

Rate

per

10

0,0

00

Popula

tion

1955 1965 1975 1985

300

700

Year

Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998

Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.

SpecializationA Proven Problem Solving Approach

SpecializationA Proven Problem Solving Approach

Identify disease

Determine causes



Identify disease

Determine causes



Repeat steps 1-4, as necessary!Repeat steps 1-4, as necessary!

But “Solutions” Can Also Create New Problems

But “Solutions” Can Also Create New Problems

Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904.

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

Side Effects of SpecializationSide Effects of SpecializationConfusion, inefficiency, organizational disarray

Competition for shared resources

Attention to “local” causes, near in time and space

Neglected feedback (+ and -)

Confounded evaluations

Coercive power dynamics

Priority on a single value, implicitly or explicitly devaluing others

Limited mandate to address context (living conditions) or infrastructure (public strength)

Disappointing track record, especially with regard to inequalities

Confusion, inefficiency, organizational disarray

Competition for shared resources

Attention to “local” causes, near in time and space

Neglected feedback (+ and -)

Confounded evaluations

Coercive power dynamics

Priority on a single value, implicitly or explicitly devaluing others

Limited mandate to address context (living conditions) or infrastructure (public strength)

Disappointing track record, especially with regard to inequalities

A

C

BD

E

A B C D EIssue Organizations

Neighborhood

Diseases of DisarrayDiseases of Disarray

Hardening of the categories

Tension headache between treatment and prevention

Hypocommitment to training

Cultural incompetence

Political phobia

Input obsession

Hardening of the categories

Tension headache between treatment and prevention

Hypocommitment to training

Cultural incompetence

Political phobia

Input obsession

Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.

Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.

Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

Source: Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2003. Accessed March 21 at <http://apps.nccd.cdc.gov/HRQOL/>.

The picture looks different if we think about people’s overall state of health or affliction

The picture looks different if we think about people’s overall state of health or affliction

14% increase

Misleading Framing AssumptionsMisleading Framing AssumptionsStepwise progress will lead to system wide improvement

Focus on the events

Everything that happens must have a cause

That cause must be close in time and space

Instantaneous impacts

Causality runs one-way

Independence

Impacts are linear and constant

Stepwise progress will lead to system wide improvement

Focus on the events

Everything that happens must have a cause

That cause must be close in time and space

Instantaneous impacts

Causality runs one-way

Independence

Impacts are linear and constant

Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.

These assumptions overlook non-local forces of change, such as feedback and delay

These assumptions overlook non-local forces of change, such as feedback and delay

Basic Problem Solving OrientationsBasic Problem Solving Orientations

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

Event Oriented View

Problem Results

Goals

Situation

Decision

SideEffects

Feedback View

Goals

Environment

Decisions

Goals ofOthers

Actions ofOthers

“When we attribute behavior to

people rather than system structure

the focus of management becomes

scapegoating and blame rather than

the design of organizations in which

ordinary people can achieve

extraordinary results.”

“When we attribute behavior to

people rather than system structure

the focus of management becomes

scapegoating and blame rather than

the design of organizations in which

ordinary people can achieve

extraordinary results.”

-- John Sterman-- John Sterman

Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.

“The tendency to blame other people instead of the system is so strong

that psychologists call it the fundamental attribution error.”

“The tendency to blame other people instead of the system is so strong

that psychologists call it the fundamental attribution error.”

Is there some way to get a larger,

more dynamic overview of the

whole health system without

loosing sight of unique disease

processes?

Is there some way to get a larger,

more dynamic overview of the

whole health system without

loosing sight of unique disease

processes?

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

Good Quality of Life Until Death

Social and Environmental Conditions Favorable to Health

Behavioral Patterns that Promote Health

Low Population Risk

Few Events/ Only Rare Deaths

Full Functional Capacity/Low Risk of Recurrence

A Vision of the Future

Policy and Environmental Change

Behavior Change

Risk Factor Detection and Control Emergency

Care/Acute CaseManagement

Rehabilitation/ Long-term Case Management

InterventionApproaches

End-of-Life Care

Target Population - USTotal Population

281 millionIncreased Risk

tens of millionsper factor

Acute Events hundreds of

thousands per event

Chronic Afflictions hundreds of thousands

per condition

A Comprehensive Public Health Framework For Chronic Disease Prevention and Health Promotion

A Comprehensive Public Health Framework For Chronic Disease Prevention and Health Promotion

Fatal Complications

Unfavorable Social and Environmental Conditions

Adverse Behavioral Patterns

Major Risk Factors

First Event/ Diagnosis

Disability/Risk of Recurrent Episodes

The Present Reality

Goal 1 Goal 3 Goal 4 Goal 2

Increase Quality and Years of Healthy Life

Eliminate Disparities

Intervention Goals (based on Healthy People 2010, Heart Disease/Stroke)

HP 2O1O

Patterns

Events

Progression of Systems Thinking & Modeling

Progression of Systems Thinking & Modeling

Adapted from: Successful Systems, Inc.

IssueIdentification

Variable & Behavior Analysis

Time

IssueIdentification

Variable & Behavior Analysis

Causal Loop Mapping

Understanding Strategy &Policy Implications

Implementing Action Plan

StructureCausal Loop

MappingSimulationModeling

Time Series ModelsDescribe trends

Multivariate Stat Models

Identify historical trend drivers and correlates

Patterns

Structure

Events

Increasing:

• Depth of causal theory

• Degrees of uncertainty

• Robustness for longer-term projection

• Value for developing policy insights

Increasing:

• Depth of causal theory

• Degrees of uncertainty

• Robustness for longer-term projection

• Value for developing policy insights

Dynamic Models

Anticipate future trends, and find policies that maximize chances

of a desirable path

Tools for Policy DevelopmentTools for Policy Development

Developed by Jack Homer, Homer ConsultingDeveloped by Jack Homer, Homer Consulting

Different Modeling Approaches For Different Purposes

Different Modeling Approaches For Different Purposes

Logic Models

(flowcharts, maps or diagrams)

System Dynamics

(causal loop diagrams and simulation models)

Forecasting

Models

Articulate steps between program actions and results

Improve understanding about the possible effects of a policy over time

Focus on patterns of change over time (e.g., long

delays, worse before better)

Make accurate forecasts of key variables

Focus on precision of point predictions and confidence intervals

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Afflicted

Afflictedwithout

Complications DevelopingComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Afflicted withComplications

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

From: 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.

CDC Futures InitiativeReport from the Health Systems Workgroup

CDC Futures InitiativeReport from the Health Systems Workgroup

Figure 1 Health system dynamics

Public Work (organizing, governance, citizenship, mutual accountability)

Professional Work (customers, products, services)

more inter-organizationally complex, slower rate of improvement

organizationally complex, faster rate of improvement

FOR SELF INTEREST FOR OTHERS IN NEED

What Kinds of Work are Needed?What Kinds of Work are Needed?

Safer,Healthier

Population

VulnerablePopulationBecoming

Vulnerable


Afflictedwithout

ComplicationsBecomingAfflicted


DevelopingComplications


Primaryprevention

Secondaryprevention

Tertiaryprevention

Generalprotection

Targetedprotection



PublicWork

Dependence on Living ConditionsDependence on Living Conditions

Corning PA. Presidential speech: the systems sciences in the year 3000. International Society of the Systems Sciences, 2000. Accessed April 23, 2002 at <http://www.complexsystems.org/commentaries/jul00.html>.

"Each of us has an array of basic needs that must, by and large,

be satisfied continuously. We cannot, for instance, do for very

long without fresh water, or waste elimination, or sleep.

Accordingly, each of us–individually and collectively–requires a

synergistic ‘package' of resources and suitable environmental

conditions. A society that can reliably provide this package will

thrive and possibly grow larger. But if even one of these needs

is not satisfied–if any part of the package is deficient–the entire

enterprise is likely to be threatened"

"Each of us has an array of basic needs that must, by and large,

be satisfied continuously. We cannot, for instance, do for very

long without fresh water, or waste elimination, or sleep.

Accordingly, each of us–individually and collectively–requires a

synergistic ‘package' of resources and suitable environmental

conditions. A society that can reliably provide this package will

thrive and possibly grow larger. But if even one of these needs

is not satisfied–if any part of the package is deficient–the entire

enterprise is likely to be threatened"

“Living conditions are the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic

circumstances and the physical environment – all of which can impact

upon health – and are largely outside of the immediate control of the individual.”

“Living conditions are the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic

circumstances and the physical environment – all of which can impact

upon health – and are largely outside of the immediate control of the individual.”

-- World Health Organization-- World Health Organization

Definition:Living Conditions

Definition:Living Conditions

World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.

Prerequisite Conditions for HealthPrerequisite Conditions for Health

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

Endorsed at all five world conferences on health promotion (1986-2000)

Endorsed at all five world conferences on health promotion (1986-2000)

Peace

Shelter

Education

Food

Peace

Shelter

Education

Food

Income

Stable eco-system

Sustainable resources

Social justice and equity

Income

Stable eco-system

Sustainable resources

Social justice and equity

Human Development FreedomsHuman Development Freedoms

Health

Education

Standard of living

Political participation

Social engagement

Physical security

Health

Education

Standard of living

Political participation

Social engagement

Physical security

Sen AK. Development as freedom. New York: Anchor books, 1999.

United Nations Development Programme. Human development report 2002: deepening democracy in a fragmented world. New York: Oxford University Press; 2002.

UNDP Human Development Index

UNDP Human Development Index

Seeing Conditions as FreedomsSeeing 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

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

Linking Living Conditions to FreedomsLinking Living Conditions to FreedomsHealthy State Freedom From… Selected Examples

Physical security Physical extremes Crash, fire, fall

Heat, cold

Radiation

Hazardous substances

Natural disaster

Infectious diseases

Peace Violence Homicide

Suicide

War

Rape

Minimal standard of living

Deprivation Malnutrition

Homelessness

Poverty

Joblessness

Overcrowding

Illiteracy

Inadequate education

Social engagement Disconnection Inequality

Injustice

Dependency

Incarceration

Runaway

Neglect

Stable organic processes

Impaired metabolism

Heart disease

Cancer

Stroke

Diabetes

Arthritis

Obesity

Mental/emotional balance

Impaired cognition or emotion

Depression

Anxiety

Attention deficit

Lack of recreation

Successful reproduction

Impaired reproduction

Infertility

Miscarriage

Birth defects

Infant mortality

Choice and Non-ChoiceChoice 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.”

“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.”

Balancing Two Areas of EmphasisBalancing Two Areas of Emphasis

World of Providing…

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

Medical and Public Health Policy

DISEASE AND RISK MANAGEMENT

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

Safer,Healthier

Population


Vulnerable


Afflictedwithout





Primaryprevention

Secondaryprevention

Tertiaryprevention

Generalprotection

Targetedprotection



PublicWork

On Protection and LeadershipOn Protection and Leadership

"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…”

"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…”

-- Nainoa Thompson-- Nainoa Thompson

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>.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>.

Two Policy OrientationsTwo Policy Orientations

Adapted from: Hancock T. Beyond health care: from public health policy to healthy public policy. Can J Public Health 1985;76 Suppl 1:9-11.Adapted from: Hancock T. Beyond health care: from public health policy to healthy public policy. Can J Public Health 1985;76 Suppl 1:9-11.

Healthy Public Policy and Public Work Medical and Public Health Policy

Concerned chiefly with expanding people’s freedom to be safe and healthy

Concerned chiefly with preventing and alleviating specific diseases, managing complications, and delaying premature death or disability

Relies heavily on multiple, small-scale, local solutions, with low technology

Relies heavily on specific high-technology solutions, widely applied

Combines analyses into a broad systems view, transcending sector boundaries

Confines analyses to the health sector

Future-oriented (reacting to long-term dynamics)

Present-oriented (reacting to immediate events)

Questions the givens, focuses on plausible outcomes

Accepts the givens, focuses on probable outcomes

Evaluated first through simulation, then through implementation

Evaluated through implementation

Main resources are citizen leadership and broad-based public work (including that of professionals)

Main resources are money, professional expertise, and technology (often excluding citizen leadership)

Could the behavior of this system be modeled mentally, or with conventional epidemoiological methods

(e.g., logistic or multi-level regression)?

Could the behavior of this system be modeled mentally, or with conventional epidemoiological methods

(e.g., logistic or multi-level regression)?

How Do We Craft High Leverage Policies?How Do We Craft High Leverage Policies?

Safer,Healthier

Population


Vulnerable


Afflictedwithout





Primaryprevention

Secondaryprevention

Tertiaryprevention

Generalprotection

Targetedprotection



PublicWork

Dynamic Models Let Us Search for Policies with the Greatest LeverageDynamic Models Let Us Search for Policies with the Greatest Leverage

Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options: they provide added foresight

Such models open new avenues for planning and formally evaluating prevention policies

Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options: they provide added foresight

Such models open new avenues for planning and formally evaluating prevention policies

Prototype of a health system simulation modelPrototype of a health system simulation model

Re-Directing the Course of ChangeQuestions from System Modeling and Social Navigation

Re-Directing the Course of ChangeQuestions from System Modeling and Social Navigation

20202010

Prevalence of Diagnosed Diabetes, US

0

5

10

15

1980 1985 1990 1995 2000

Mill

ion

peop

le

Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.

How?

Why?

Where?

Who?

“Let me assure you, we will survive any crisis

that involves funding, political support,

popularity, or cyclic trends, but we can't

survive the internal crisis, if we become

provincial, focus totally on the short term, or

if we lose our philosophy of social justice.”

“Let me assure you, we will survive any crisis

that involves funding, political support,

popularity, or cyclic trends, but we can't

survive the internal crisis, if we become

provincial, focus totally on the short term, or

if we lose our philosophy of social justice.”

-- William Foege-- William Foege

Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.

Progress in Dynamic ModelingProgress in Dynamic Modeling

The Dynamics of Upstream and Downstream Why is it so hard for the health system to work upstream, and what can be done about it? (Milstein & Homer, with the CDC Futures Health System Workgroup)

The System-wide Drivers of Diabetes What are the system-wide drivers of type 2 diabetes incidence and progression, including other chronic illnesses, risk factors, and multiple types of prevention and protection programs?(CDC Diabetes System Modeling Project)

The Problem of Outside AssistanceWhat types of outside assistance are most effective in reducing the overall burden of affliction (unhealthy days) in communities with multiple afflictions? (Homer & Milstein 2002, 2004; web game)

The Dynamics of Upstream and Downstream Why is it so hard for the health system to work upstream, and what can be done about it? (Milstein & Homer, with the CDC Futures Health System Workgroup)

The System-wide Drivers of Diabetes What are the system-wide drivers of type 2 diabetes incidence and progression, including other chronic illnesses, risk factors, and multiple types of prevention and protection programs?(CDC Diabetes System Modeling Project)

The Problem of Outside AssistanceWhat types of outside assistance are most effective in reducing the overall burden of affliction (unhealthy days) in communities with multiple afflictions? (Homer & Milstein 2002, 2004; web game)

For Additional Informationhttp://www.cdc.gov/syndemics

Background on Dynamic Modeling Projects

Work in Progress

Background on Dynamic Modeling Projects

Work in Progress

Benefits of Game-Based LearningBenefits of Game-Based Learning

Formal means of evaluating options

Compressed time

Actions can be stopped or reversed

Experimental control of all conditions

Complete, undistorted, immediate results

Rehearse worse-before-better scenarios

Early warning of unintended effects

Opportunity to assemble stronger support

Formal means of evaluating options

Compressed time

Actions can be stopped or reversed

Experimental control of all conditions

Complete, undistorted, immediate results

Rehearse worse-before-better scenarios

Early warning of unintended effects

Opportunity to assemble stronger support

“Artful scenario spinning…ensures not that you are always right about the future but--better--that you are almost never wrong."

-- Stewart Brand

“Artful scenario spinning…ensures not that you are always right about the future but--better--that you are almost never wrong."

-- Stewart Brand

Progress in Dynamic ModelingProgress in Dynamic Modeling

Problem Focus Stage of Development

Outside assistance in communities with multiple afflictions

Most exploratory

Designed to explore interactions between afflictions, living conditions, and public strength

Dynamics of upstream and downstream health work

More empirically supported

Designed to understand an observed phenomenon, the 97% -- 3% split in health care expenditures

Dynamics of diabetes incidence and progression

Most empirically supported

Steps for Putting Maps in MotionSteps for Putting Maps in MotionIdentify a persistent problem that exists, in part, due to dynamic complexity (i.e., forces of feedback, delay, non-linearity, etc…)

Develop a preliminary dynamic hypothesis (i.e., what causal forces are at work?)

Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on available data; areas of uncertainty are noted and become the focus for sensitivity analysis)

Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time

Iteratively repeat the process, creating better hypotheses, better models, better policy insight, and more effective action

Identify a persistent problem that exists, in part, due to dynamic complexity (i.e., forces of feedback, delay, non-linearity, etc…)

Develop a preliminary dynamic hypothesis (i.e., what causal forces are at work?)

Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on available data; areas of uncertainty are noted and become the focus for sensitivity analysis)

Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time

Iteratively repeat the process, creating better hypotheses, better models, better policy insight, and more effective action

Why Is it So Hard to Work Upstream?A Preliminary Dynamic Hypothesis

Why Is it So Hard to Work Upstream?A Preliminary Dynamic Hypothesis

Upstream Prevention and Protection-----------------------------------Total 3%

Downstream Care and Management--------------------------------Total 97%

Brown R, Elixhauser A, Corea J, Luce B, Sheingod S. National expenditures for health promotion and disease prevention activities in the United States. Washington, DC: Battelle; Medical Technology Assessment and Policy Research Center; 1991. Report No.: BHARC-013/91-019.

Safer,Healthier

Population

VulnerablePopulation

Becomingvulnerable


Afflictedwithout

ComplicationsBecomingafflicted


Developingcomplications


Health System DynamicsHealth System Dynamics

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Downstreamwork

Professionalconcern


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onprogression

-

Effect oncomplications

-

TertiaryPrevention

SecondaryPrevention

Downstreamwork

Professionalconcern


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout






-


-

TertiaryPrevention

SecondaryPrevention

Vulnerable andAfflicted Popn

Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

Publicwork


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-

Effect on livingconditions

Effect onvulnerabilityreduction

GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

-

Publicwork


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

Citizen Involvementand Organizing

-

Publicwork


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-


SocialDivision

-

Publicwork


Downstream lock-in: Delay in upstream effort guarantees continued growth in affliction prevalence and emphasis on treatment, which further delays upstream effort, as does mounting social disparity.


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-


SocialDivision

-

PublicworkInstitutional/organizational

emphasis on diseaserather than vulnerability

-

Prototype of a Dynamic Health System Simulation

Work in Progress

Prototype of a Dynamic Health System Simulation

Work in Progress

Building a Dynamic HypothesisBuilding a Dynamic Hypothesis

GeneralPopulation Vulnerability

onset

Vulnerabilityreduction

VulnerablePopulation Affliction

incidence

Afflictedwithout

Complications Afflictionprogression

afflicted percent of

Public healthresponse

Complicated

popn

-

General protectioneffect on vulnerability

onset

B General Protection

Targeted protectioneffect on vulnerability

reduction

B Targeted Protection


Death fromComplications

-

Secondary preventioneffect on progression

B

SecondaryPrevention

Primary preventioneffect on incidence

-

B

Primary Prevention

Tertiary preventioneffect on

complications

-

B

Treatment

Note: for this initial model, the system being modeled includes only a subset of the dynamics that were identified in the conceptual map.

Active Equations (01) Afflicted = Afflicted without Complications + Afflicted with Complications

(02) Afflicted with Complications = INTEG( Affliction progression - Death from Complications , 0)

(03) Afflicted without Complications = INTEG( Affliction incidence - Affliction progression , 0)

(04) Affliction incidence = Vulnerable Popn * Affliction incidence rate baseline * Primary prevention effect on incidence

(05) Affliction incidence rate baseline = 0.05

(06) Affliction progression = Afflicted without Complications * Affliction progression rate baseline * Secondary prevention effect on progression

(07) Affliction progression rate baseline = 0.1

(08) Complicated afflicted percent of popn = 100 * Afflicted with Complications / Total popn

(09) Complicated afflicted percent required to elicit maximum PH response = 20

(10) Complicated percent of afflicted = 100 * ZIDZ ( Afflicted with Complications , Afflicted )

(11) Complications death rate baseline = 0.1

Writing Differential EquationsWriting Differential Equations

(12) Death from Complications = Afflicted with Complications * Complications death rate baseline * Tertiary prevention effect on complications

(13) General Popn = INTEG( Net increase in genl popn + Vulnerability reduction - Vulnerability onset , Total popn initial * ( 100 - Vulnerable percent initial ) / 100)

(14) General protection effect from max PHR = 0.5

(15) General protection effect on vulnerability onset = 1 - ( 1 - General protection effect from max PHR ) * Public health response / 100

(16) Net increase in genl popn = Death from Complications * ( 1 - Vulnerable percent of nonafflicted / 100)

(17) Net increase in vulnerable popn = Death from Complications * Vulnerable percent of nonafflicted / 100

(18) Nonafflicted = General Popn + Vulnerable Popn

(19) Primary prevention effect from max PHR = 0.5

(20) Primary prevention effect on incidence = 1 - ( 1 - Primary prevention effect from max PHR ) * Public health response / 100

(21) Public health response = DELAY1I ( 100 * MIN ( 1, Complicated afflicted percent of popn / Complicated afflicted percent required to elicit maximum PH response ) , Time for public health to respond to affliction prevalence , 0)


(22) Secondary prevention effect from max PHR = 0.5

(23) Secondary prevention effect on progression = 1 - ( 1 - Secondary prevention effect from max PHR ) * Public health response / 100

(24) Targeted protection effect from max PHR = 2

(25) Targeted protection effect on vulnerability reduction = 1 + ( Targeted protection effect from max PHR - 1) * Public health response / 100

(26) Tertiary prevention effect from max PHR = 0.5

(27) Tertiary prevention effect on complications = 1 - ( 1 - Tertiary prevention effect from max PHR ) * Public health response / 100

(28) Time for public health to respond to affliction prevalence = 2

(29) Total popn = Nonafflicted + Afflicted

(30) Total popn initial = 100000

(31) Vulnerability onset = General Popn * Vulnerability onset rate baseline * General protection effect on vulnerability onset

(32) Vulnerability onset rate baseline = 0.05


(33) Vulnerability reduction = Vulnerable Popn * Vulnerability reduction rate baseline * Targeted protection effect on vulnerability reduction

(34) Vulnerability reduction rate baseline = 0.07

(35) Vulnerable percent initial = 10

(36) Vulnerable percent of nonafflicted = 100 * Vulnerable Popn / Nonafflicted

(37) Vulnerable Popn = INTEG( Net increase in vulnerable popn + Vulnerability onset - Affliction incidence - Vulnerability reduction , Total popn initial * Vulnerable percent initial / 100)


Parameter Assumption

Population Characteristics

Total population initially 100,000

Percent afflicted initially 0%

Percent vulnerable initially 10%

Developing Assumptions For Response Scenarios



Baseline Epidemiological Characteristics

Vulnerability onset rate (% per year among general pop) 5%

Vulnerability reduction rate (% per year among vulnerable) 7%

Affliction incidence rate (% per year among vulnerable) 5%

Affliction progression rate (% per year among afflicted without complications)

10%

Complications death rate (% per year among afflicted with complications)

10%




Health System Characteristics

Complicated affliction prevalence required to elicit maximum health system response (lower prevalence elicits proportionally smaller response)

20%

Time for organizing a health system response to complicated affliction prevalence

2 years




Effect of Health System Responses

Tertiary prevention effect on deaths from complications ?

Secondary prevention effect on affliction progression ?

Primary prevention effect on affliction incidence ?

Targeted protection effect on vulnerability reduction ?

General protection effect on vulnerability onset ?

Making Decisions About How to RespondMaking Decisions About How to Respond

Response Scenario

Effect of Health System Response on…

40-Year Simulation Results

DeathsAffliction Progress

Affliction Incidence

Vulnerable Reduction

Vulnerable Onset

Percent

Afflicted w/ Complication

(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1

Prev 3 0.5 1 1 1 1

Prev 2+3 0.5 0.5 1 1 1

Prev 1+2+3 0.5 0.5 0.5 1 1

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5

Developing a Scenario-based Research DesignDeveloping a Scenario-based Research Design

Putting the System in MotionPutting the System in Motion

Afflicted with Complications

20,000

10,000

0

0 4 8 12 16 20 24 28 32 36 40Time

Afflicted with Complications : NoRespAfflicted with Complications : Prev3Afflicted with Complications : Prev23Afflicted with Complications : Prev123Afflicted with Complications : Prev123Prot2Afflicted with Complications : Prev123Prot12

Interpreting Behavior Over TimeInterpreting Behavior Over Time

Response Scenario






Vulnerable Onset

Percent


(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1 11%

Prev 3 0.5 1 1 1 1 14%

Prev 2+3 0.5 0.5 1 1 1 12%

Prev 1+2+3 0.5 0.5 0.5 1 1 11%

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1 10%

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5 9%


Vulnerable Popn

40,000

32,000

24,000

16,000

8,000

0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time

Vulnerable Popn : NoRespVulnerable Popn : Prev3Vulnerable Popn : Prev23Vulnerable Popn : Prev123Vulnerable Popn : Prev123Prot2Vulnerable Popn : Prev123Prot12


Response Scenario






Vulnerable Onset

Percent


(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1 11% 25%

Prev 3 0.5 1 1 1 1 14% 24%

Prev 2+3 0.5 0.5 1 1 1 12% 24%

Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26%

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1 10% 22%

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5 9% 19%


Public health response

80

64

48

32

16

0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time

Public health response : NoRespPublic health response : Prev3Public health response : Prev23Public health response : Prev123Public health response : Prev123Prot2Public health response : Prev123Prot12


Response Scenario






Vulnerable Onset

Percent


(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1 11% 25% 0%

Prev 3 0.5 1 1 1 1 14% 24% 69%

Prev 2+3 0.5 0.5 1 1 1 12% 24% 60%

Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26% 53%

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1 10% 22% 50%

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5 9% 19% 47%


Diabetes System Modeling Project Work in Progress

Diabetes System Modeling Project Work in Progress

Forecast of Diabetes PrevalenceForecast of Diabetes Prevalence


0

10

20

30

40

1980 1990 2000 2010 2020 2030 2040 2050

Mill

ion

pe

op

le

Historical Data: CDC DDT and NCCDPHP. (Change in measurement in 1996).Model Forecast: Honeycutt et al. 2003, "A Dynamic Markov model…"

HistoricalData

ModelForecast

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

Focusing on the More Modifiable Drivers

Focusing on the More Modifiable Drivers

Prevalence of Diagnosed Diabetes, USHistorical and Forecasted

0

10

20

30

40

1980 1990 2000 2010 2020 2030 2040 2050

Mill

ion

peop

le

Historical Data: CDC DDT and NCCDPHP. (Change in measurement in 1996).Model Forecast: Honeycutt et al. 2003, "A Dynamic Markov model…"

Due to Population Growth

Due to Changes in Prevalence Fractions

Due to Changes in Demographic Mix

54%

20%

26%

Re-Directing the Course of ChangeRe-Directing the Course of Change

20202010


0

5

10

15

1980 1985 1990 1995 2000

Mill

ion

peop

le

Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.

How?

Why?

Where?

Who?

Diabetes System Modeling ProjectDiabetes System Modeling Project

CDC-Wide Champions

Observers and Other Constituents

Initial Model Conceptualization Team

Program Branch

NCCDPHPSenior Staff

Office of Director

Epidemiology BranchCardiovascular

Health

Nutrition and Physical Activity

Adult andCommunity Health

Adolescent and School Health

Public Health

Practice

Division of Diabetes Translation

DynamicModelingExperts

Smoking and Health

Non-Diabetics

Diabetics

Diabetes onset

Diabetes Population FlowsDiabetes 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

Diabetics

Non-Diabetics



DiagnosedStage 1

Diabetics

Stage 2Diabetics


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

Diabetics

Non-Diabetics

DiagnosedStage 1

Diabetics

Stage 2Diabetics


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

Tertiary Prevention: Disease Management for Stage 2 Diabetics

Diabetics

Non-Diabetics


DiagnosedStage 1

Diabetics

Stage 2Diabetics


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

Secondary Prevention: Screening for Diabetes & Disease Mgmt for Stage 1 Diabetics

Diabetics

Non-Diabetics


DiagnosedStage 1

Diabetics

Stage 2Diabetics


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

Primary Prevention: Screening for Prediabetes & Nutrition/Activity for High Risk Individuals

Diabetics

Non-Diabetics


Targeted Protection: Risk Factor Elimination for High Risk Individuals

Diabetics

Non-Diabetics


DiagnosedStage 1

Diabetics

Stage 2Diabetics


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

DiagnosedStage 1

Diabetics

Stage 2Diabetics


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

General Protection: Changing Risk Conditions of the General and High Risk Populations

Diabetics

Non-Diabetics


Where is the Greatest Leverage?Comparing Program Strategies,

Alone and in Combination

Where is the Greatest Leverage?Comparing Program Strategies,

Alone and in Combination

Diabetes education for the public

Diabetes education for providers

Weight reduction programs for the obese

Resources for diabetes disease management

Resources for glycemic screening

Facilitating greater food choice

Facilitating greater availability of affordable health care

Facilitating greater social and cultural support for the underserved

Facilitating improvements in built environment and public safety

Facilitating more work opportunities

Others….

Diabetes education for the public

Diabetes education for providers

Weight reduction programs for the obese

Resources for diabetes disease management

Resources for glycemic screening

Facilitating greater food choice

Facilitating greater availability of affordable health care

Facilitating greater social and cultural support for the underserved

Facilitating improvements in built environment and public safety

Facilitating more work opportunities

Others….

Conducting Policy Experiments Conducting Policy Experiments

Population Breakdown Based on National Statistics

Population Breakdown Based on National Statistics

Total Population

Diabetics 6%

22%

Status within Diabetics

Undiagnosed 32%

Diagnosed stage 1 diabetics 35%

Diagnosed stage 2 diabetics 33%

Within the high risk group, we calculate 25-45% have IGT and 33-60% are Prediabetic (IGT or IFG)*

* Lower numbers based on Benjamin et al. 2003, higher numbers based on NIDDK estimates. IGT: Impaired Glucose Tolerance, 2 hr. non-fasting, 140-199 mg/dl; IFG: Impaired Fasting Glucose, 110-125

mg/dl

Generalpopulation

72%

High risk22%

Data Sources for Initial CalibrationData Sources for Initial CalibrationHigh Risk Population, Incidence, Prevalence, Deaths

“National Diabetes Statistics”: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm“Prevalence of Selected Chronic Conditions: United States, 1990-1992”: www.cdc.gov/nchs/data/series/sr_10/sr10_194.pdf“Healthy People 2000 Review, 1997”: www.cdc.gov/nchs/data/hp2000/hp2k97.pdf“Deaths: Preliminary Data for 2000”: www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf“Estimated number of adults with prediabetes in the U.S. in 2000: Opportunities for prevention”, Benjamin SM et al (DDT/CDC), Diabetes Care 26: 645-9, 2003.“A Dynamic Markov Model for Forecasting Diabetes Prevalence in the United States through 2050”, Honeycut AA et al. (DDT/CDC), Health Care Mgmt Sci 6: 155-164, 2003.

Complications and Benefits of Control“Model of Complications of NIDDM--1. Model Construction and Assumptions”, Eastman RC et al, Diabetes Care 20: 725-734, 1997.“Model of Complications of NIDDM--2. Analysis of the Health Benefits and Cost-Effectiveness of Treating NIDDM with the Goal of Normoglycemia”, Eastman RC et al., Diabetes Care 20: 735-744, 1997.“The Prevention or Delay of Type 2 Diabetes”, position statement from ADA and NIDDK, Diabetes Care 25: 742-749, 2002“Effect of Improved Glycemic Control on Health Care Costs and Utilization”, EH Wagner et al., JAMA 285: 182-189, 2001“Health Economic Benefits and Quality of Life During Improved Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Randomized, Controlled Double-Blind Trial”, Testa MA and Simonson DC, JAMA, 280: 1490-6, 1998

High Risk Population, Incidence, Prevalence, Deaths“National Diabetes Statistics”: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm“Prevalence of Selected Chronic Conditions: United States, 1990-1992”: www.cdc.gov/nchs/data/series/sr_10/sr10_194.pdf“Healthy People 2000 Review, 1997”: www.cdc.gov/nchs/data/hp2000/hp2k97.pdf“Deaths: Preliminary Data for 2000”: www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf“Estimated number of adults with prediabetes in the U.S. in 2000: Opportunities for prevention”, Benjamin SM et al (DDT/CDC), Diabetes Care 26: 645-9, 2003.“A Dynamic Markov Model for Forecasting Diabetes Prevalence in the United States through 2050”, Honeycut AA et al. (DDT/CDC), Health Care Mgmt Sci 6: 155-164, 2003.

Complications and Benefits of Control“Model of Complications of NIDDM--1. Model Construction and Assumptions”, Eastman RC et al, Diabetes Care 20: 725-734, 1997.“Model of Complications of NIDDM--2. Analysis of the Health Benefits and Cost-Effectiveness of Treating NIDDM with the Goal of Normoglycemia”, Eastman RC et al., Diabetes Care 20: 735-744, 1997.“The Prevention or Delay of Type 2 Diabetes”, position statement from ADA and NIDDK, Diabetes Care 25: 742-749, 2002“Effect of Improved Glycemic Control on Health Care Costs and Utilization”, EH Wagner et al., JAMA 285: 182-189, 2001“Health Economic Benefits and Quality of Life During Improved Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Randomized, Controlled Double-Blind Trial”, Testa MA and Simonson DC, JAMA, 280: 1490-6, 1998

One benefit of the modeling process can be knowledge integrationOne benefit of the modeling process can be knowledge integration

Response Scenario


Controled Fraction of

S2

Controled Fraction of

S1

Diabetes Diagnosis

Rate

Onset Rate for Dx PreD

Onset Rate for

UnDx PreD

PreD Diagnosis

Rate

PreD Onset Rate

Rehab of Dx PreD Rate

Rehab of High Risk UnDx PreD Rate

Become High Risk Rate

Steady State .2 .2 .06 .025 .045 .04 .065 .06 .03 .02

Prev 3 .5 " " " " " " " " "

Prev 2+3 .5 .5 .12 " " " " " " "

Prev 1+2+3 .5 .5 .12 .020 .040 .08 .55 " " "

Prev 2+3

Prot 2.5 .5 .12 " " " " .10 .05 "

Prev 1+2+3 +

Prot 1+2.5 .5 .12 .020 .040 .08 .55 .10 .05 .01

Developing a Scenario-based Research DesignDeveloping a Scenario-based Research Design

Model Tests Start in a Steady-StateModel Tests Start in a Steady-State

The model is initialized in a steady state or “dynamic equilibrium”

No change in total population: Births = Total deaths

Every population stock has inflows exactly cancelled by outflows

In the base (“flatline”) run, all input time series are unchanging

Any changes in the time series inputs (pink) will disturb the steady state and cause the population system to move toward a new equilibrium

By putting the model in an initial equilibrium we are able to examine the effects of changes in the time series inputs in isolation from general population trends (which will be added in a future version)

The model is initialized in a steady state or “dynamic equilibrium”

No change in total population: Births = Total deaths

Every population stock has inflows exactly cancelled by outflows

In the base (“flatline”) run, all input time series are unchanging

Any changes in the time series inputs (pink) will disturb the steady state and cause the population system to move toward a new equilibrium

By putting the model in an initial equilibrium we are able to examine the effects of changes in the time series inputs in isolation from general population trends (which will be added in a future version)

Interpreting Behavior Over TimeInterpreting Behavior Over TimeS2 complications deaths

600,000

300,000

0

0 4 8 12 16 20 24 28 32 36 40Time

S2 complications deaths : prev123prot12S2 complications deaths : prot12prev1S2 complications deaths : prev23S2 complications deaths : prev3S2 complications deaths : Steady state

Interpreting Behavior Over TimeInterpreting Behavior Over TimeProgression of Diagnosed S1 to S2

600,000

480,000

360,000

240,000

120,000

0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time

Progression of Diagnosed S1 to S2 : prev123prot12 people per yearProgression of Diagnosed S1 to S2 : prot12prev1 people per yearProgression of Diagnosed S1 to S2 : prev23 people per yearProgression of Diagnosed S1 to S2 : prev3 people per yearProgression of Diagnosed S1 to S2 : Steady state people per year

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


S2 deaths

High RiskNot

Prediabetic

UndiagnosedStage 1

Diabetics



GeneralPopulation

BecomeHigh Risk

Rehab ofHigh Risk






Prediabetesonset

Rehab ofUndx PreD

Rehab ofDx PreD

DRAFT: Diabetes System Sector Sketch (December 4-5, 2003)DRAFT: Diabetes System Sector Sketch (December 4-5, 2003)

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

Included in version 1

Not included in version 1

How Does Outside Assistance Affect Communities Facing Multiple Afflictions?

Work in Progress

How Does Outside Assistance Affect Communities Facing Multiple Afflictions?

Work in Progress

What Are the Dynamics of Outside Assistance in Communities Facing Multiple Afflictions?

A Preliminary Dynamic Hypothesis

What Are the Dynamics of Outside Assistance in Communities Facing Multiple Afflictions?

A Preliminary Dynamic Hypothesis

KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop

Afflictionprevalence &

burden

Adverseliving

conditions

Effort to alleviate andprevent affliction

Effort to improveliving conditions

R1

R3a

R4a

R4b

B1b

B1a

Communitystrength

Outside assistance toalleviate and prevent

affliction

Outside assistanceto improve living

conditions

R2b

At-risk fraction

Afflictioncross-impacts

Social disparity

R2a Public work fraction

Outside assistance tobuild community

strength

United efforts

R2c

Magnitude ofefforts

Divided efforts

R3b

Afflictionprevalence& burden

Adverseliving

conditions

Publicstrength

R1

At-risk fraction

Afflictioncross-impacts

Effort to alleviate andprevent affliction

B1a

Effort to improveliving conditions

B1b

Effort to build public strength

B1c

Social disparityR2c

R2b

R2a

R3a

Public work fraction

United efforts

Divided efforts

R3b Magnitude ofameliorative efforts

R3c

R3d

Outside assistance toalleviate and prevent

affliction

Outside assistanceto improve living

conditions

Outside assistance to build public

strength

KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop

About the Feedback LoopsAbout the Feedback LoopsSyndemic: Each affliction increases vulnerability to other afflictions, thereby amplifying the effect of increases or decreases in the prevalence of individual afflictions.

Community Response: Community residents make efforts to fight affliction and adverse living conditions in response to their prevalence, and to build greater public strength when it is perceived as low. Outside assistance may bolster such efforts.

Social Disparity and Public Strength: These efforts, especially those to fight adverse living conditions, are greater in magnitude when citizens are strong and unified through democratic public institutions. But public strength is hindered by social disparity, which, in turn, is made worse by the very afflictions and adverse living conditions the efforts are trying to fight.

Public Strength and Public Work: Public strength is also affected by the efforts themselves. When problems spread in a community with strong democratic institutions, a united response (public work) reinforces the community’s strength. Conversely, when problems spread in a community with weaker democratic institutions, a divided response (consisting of only professional work) reinforces the community’s weakness. Outside assistance given to a weaker community for problem fighting may amplify the divided response and undermine the community’s internal response capability. Outside assistance to build public strength may prepare the residents to make a more united response.

Syndemic: Each affliction increases vulnerability to other afflictions, thereby amplifying the effect of increases or decreases in the prevalence of individual afflictions.

Community Response: Community residents make efforts to fight affliction and adverse living conditions in response to their prevalence, and to build greater public strength when it is perceived as low. Outside assistance may bolster such efforts.

Social Disparity and Public Strength: These efforts, especially those to fight adverse living conditions, are greater in magnitude when citizens are strong and unified through democratic public institutions. But public strength is hindered by social disparity, which, in turn, is made worse by the very afflictions and adverse living conditions the efforts are trying to fight.

Public Strength and Public Work: Public strength is also affected by the efforts themselves. When problems spread in a community with strong democratic institutions, a united response (public work) reinforces the community’s strength. Conversely, when problems spread in a community with weaker democratic institutions, a divided response (consisting of only professional work) reinforces the community’s weakness. Outside assistance given to a weaker community for problem fighting may amplify the divided response and undermine the community’s internal response capability. Outside assistance to build public strength may prepare the residents to make a more united response.

Syndemics Simulation Game http://broadcast.forio.com/sims/syndemic2003/







Four Scenarios for Affliction Burden

Development of a SyndemicDevelopment of a Syndemic

12

10

8

6

4

0 2 4 6 8 10 12 14 16 18 20Time (years)

Affliction burden : GBasicAffliction burden : GMARCIbAffliction burden : GBALCbAffliction burden : GBCSb

Basic scenario: Poor living conditions, weak community, intertwined afflictions

Weaker cross-impacts among afflictions

Better living conditions

Greater community strength

Avg unhealthy days per person per month

Evaluating Policy ScenariosEvaluating Policy Scenarios

Focus assistance on…

Fighting affliction

Improving adverse living conditions

Building public strength

Focus assistance on…

Fighting affliction

Improving adverse living conditions

Building public strength

Different proportions

Different combinations

Different sequences

Different proportions

Different combinations

Different sequences

Alternative Investment StrategiesAlternative Investment Strategies

Public Health Programming Social Programming Democratic Organizing

12

10

8

6

4

0 2 4 6 8 10 12 14 16 18 20Time (years)

Affliction burden : BasicOptAffliction burden : BasicAF111Affliction burden : BasicLC111Affliction burden : BasicCS111

Comparing Affliction Burden under Basic Setting and Four Different Assistance Schemes

Comparing Affliction Burden under Basic Setting and Four Different Assistance Schemes

Affliction assistance only “AF111”Conditions assistance only “LC111”

Strength assistance only “CS111”

Optimal assistance scheme “CS1AF11”

Avg affliction burden T4-T20:8.18.58.88.3

Policy HypothesesInvest Early in Building Strength

Policy HypothesesInvest Early in Building Strength

The first priority of philanthropies and government in addressing communities that are weak and struggling against multiple afflictions should be to assist in building public strength (enabling a greater degree of citizen-led public work), perhaps even before substantial assistance is provided for direct fighting of prevalent diseases.

The first priority of philanthropies and government in addressing communities that are weak and struggling against multiple afflictions should be to assist in building public strength (enabling a greater degree of citizen-led public work), perhaps even before substantial assistance is provided for direct fighting of prevalent diseases.

Policy HypothesesBeware the Side Effects of Outside

Assistance Related to Living Conditions

Policy HypothesesBeware the Side Effects of Outside

Assistance Related to Living Conditions

Outside assistance aimed directly at improving living conditions may often be insufficiently cost-effective, due to time lags and unintended side effects, to warrant making such assistance a high priority in the absence of widespread citizen participation

Outside assistance aimed directly at improving living conditions may often be insufficiently cost-effective, due to time lags and unintended side effects, to warrant making such assistance a high priority in the absence of widespread citizen participation

Structural Reasons for Policy Resistance

Structural Reasons for Policy Resistance

Problem-fighting programs may have perverse effects on public strength when the community residents are weak and divided to begin with

Problem-fighting programs may have perverse effects on public strength when the community residents are weak and divided to begin with

syndemic thinking in the cdc futures initiative bobby milstein nccdphp strategy planning process...

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