Possibilities for Better Integrating System Dynamics Into Public Health Bobby Milstein 21 st International Conference of the System Dynamics Society New York, 2003
Possibilities for Better Integrating System Dynamics Into Public Health
Bobby Milstein21st International Conference of the System Dynamics Society
New York, 2003
Seeing Beyond the Probable
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.”
-- Ciement Bezold
Smallpox EradicationOur Greatest (Temporary) Victory
A Glimpse Into 2020
Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.
Starting Assumptions
Most public health agencies act as if each affliction can be prevented individually by understanding its unique causes and developing targeted interventions
This compartmentalized approach is ingrained in financial structures, problem solving frameworks, statistical models, and criteria for professional prestige
Need A Complementary Science of Relationships
Problem, problem solver, response
Coordination of multiple problems, problem solvers, and responses
Diseases of Disarray
Hardening of the categoriesTension headache between treatment and preventionHypocommitment to trainingCultural incompetencePolitical phobiaInput 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.
Spectrum of Prevention
SHORTmonths-years
INTERMEDIATEyears-decades
LONGdecades-centuries
Time Horizon for Observing Effects on Population Health Status*
* Effects on outcomes other than population health status (e.g., risk/protective behaviors, change agents, or system changes) can be observed in shorter time intervals
SECONDARY &TERTIARY
Biological Change
Healing ServicesFocus on Affliction
PRIMARY & SECONDARY
BehavioralChange
Focus on RiskDisease Prevention
INTERGENERATIONAL
Social Change
Focus on ConditionsHealth Promotion
Focus on Capacity for ActionCapacity Building or Empowerment
Infrastructural Change
Public Health Goals Are Accumulating and Becoming More Systemic
Prevent disease and injury (~1850 -- present)
Promote health and human 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
Virtually Unstoppable Trends in Prevention Science
Systems-oriented
Politically engaged
Philosophically conscious
What Is Not Happening
IntegrationDynamic hypotheses of health states and rates
Testing through simulationSearching for polices that can be effectiveRehearsing policy implementationLearning about dynamic complexity
Brief History of Causal TheoryWhat accounts for poor community health?
God’s will Humors, miasma, etherPoor 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 community capacity (syndemic)
1880
1950
1960
1980
2000
1840
Cost-effectiveness analysis: simulating patterns of disease dynamics, prevention activities, and resources
Program dynamics: simulating system-wide impacts of comprehensive programs with interacting components
Community dynamics: simulating the mediating effects of local conditions, capabilities, and constraints
Group model building: providing more structure and insight to the participatory planning process
Game-based learning: improving intuition, foresight, commitment, and agility in navigating change
Roles for System Modelingin Public Health