Syndemics and the Interface Between Public Health, Systems Science, and Social Navigation Bobby Milstein Mid-America Regional Public Health Leadership.

Syndemics and the Interface Between Public Health, Systems Science, and

Social Navigation

Syndemics and the Interface Between Public Health, Systems Science, and

Social Navigation

Bobby Milstein Mid-America Regional Public Health Leadership Institute

April 7, 2006Indianapolis, IN

Bobby Milstein Mid-America Regional Public Health Leadership Institute

April 7, 2006Indianapolis, IN

Bobby Milstein

Syndemics Prevention NetworkCenters for Disease Control and Prevention

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

Bobby Milstein

Syndemics Prevention NetworkCenters for Disease Control and Prevention

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

“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.

What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice?

What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice?

What approaches to public health work may help us to recognize and overcome these pitfalls?

What approaches to public health work may help us to recognize and overcome these pitfalls?

What single word best conveys the message of this report?

What single word best conveys the message of this report?

Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988

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.

New Word for a Familiar PhenomenonNew Word for a Familiar Phenomenon

Singer M, Snipes C. Generations of suffering: experiences of a treatment program for substance abuse during pregnancy. Journal of Health Care for the Poor and Underserved 1992;3(1):222-34.

Singer M. 1994. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Social Science and Medicine 39(7): 931-948.

Singer M. 1996. A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology 24(2): 99-110.

Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 2003;17(4):423-441.

“We have introduced the term ‘syndemic’ to refer to the set of synergistic

or intertwined and mutually enhancing health and social problems facing

the urban poor. Violence, substance abuse, and AIDS, in this sense, are not

concurrent in that they are not completely separable phenomena.”

“We have introduced the term ‘syndemic’ to refer to the set of synergistic

or intertwined and mutually enhancing health and social problems facing

the urban poor. Violence, substance abuse, and AIDS, in this sense, are not

concurrent in that they are not completely separable phenomena.”

-- Merrill Singer-- Merrill Singer

What was Singer doing?

What are the implications for public health work?

What methodologies support this perspective (scientifically, politically, morally)?

What effects do these ways of thinking and acting have in the world?

What was Singer doing?

What are the implications for public health work?

What methodologies support this perspective (scientifically, politically, morally)?

What effects do these ways of thinking and acting have in the world?

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. <http://www.cdc.gov/syndemics>.

Ongoing study of innovations in public health work

Member network includes

419 individuals

280 organizations

19 countries

Ongoing study of innovations in public health work

Member network includes

419 individuals

280 organizations

19 countries

http://www.aeinstein.org/

Starting PremisesStarting Premises

Public health work has changed significantly since its formalization in the 19th Century, and even today it is poised for further transformation

It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match

We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, and what we value

Public health work has changed significantly since its formalization in the 19th Century, and even today it is poised for further transformation

It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match

We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, and what we value

Plan for TodayPlan for Today

Explore the meaning and implications of a syndemic orientation

Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work

Illustrate how system dynamics maps and simulation models can support innovative thinking and action

Explore the meaning and implications of a syndemic orientation

Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work

Illustrate how system dynamics maps and simulation models can support innovative thinking and action

Epi·demic Epi·demic 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….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….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

Syn·demic 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 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

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 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

Systems

Co-occurring

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

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor population health?

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor population 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 public strength (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 public strength (syndemic)

1880

1950

1960

1980

2000

1840

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

Seeing SyndemicsSeeing Syndemics

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)





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

-- Sufi Saying


-- Sufi Saying

Placing Health in a Wider Set of Relationships


Health

LivingConditions

PublicStrength

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


A Philosophy of MeansA Philosophy of Means

“Social and political theory

have neglected the central

question of means, and,

therefore, the problem of

inevitable conflict.”

“Social and political theory

have neglected the central

question of means, and,

therefore, the problem of

inevitable conflict.”

-- Joan Bondurant-- Joan Bondurant

Bondurant JV. Conquest of violence: the Gandhian philosophy of conflict. New rev. ed. Princeton N J: Princeton University Press, 1988.

Toward a Complementary Science of Relationships


Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses


Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses

Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.

“True innovation occurs when things are put together for the first time that had been separate.”

– Arthur Koestler


– Arthur Koestler

Questioning the Character of Public Health WorkQuestioning the Character of Public Health WorkPUBLIC HEALTH WORK

InnovativeHealth

Ventures

SYSTEMS THINKING & MODELING (understanding change)

• 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)?

PUBLIC HEALTH(setting direction)

What are health leaderstrying to accomplish?

SOCIAL NAVIGATION(governing movement)

Directing Change

Charting Progress

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

• How are conditions changing?• In which directions?

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

Syndemic OrientationWorking Definition

Syndemic OrientationWorking Definition

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

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.

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.

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

System Dynamics

SocialNavigation

POLICYDEVELOPMENT

ASSESSMENT

ASSURANCE

NetworkAnalysis

CategoricalOrientationSyndemic

Orientation

“Solutions” CanCreate New Problems

“Solutions” CanCreate 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.

Many Systems Exhibit Policy ResistanceMany Systems Exhibit Policy Resistance

Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35.

Pear R. Health spending rises to record 15% of economy. The New York Times 2004 January 9.

Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.

“At least six times since the

Depression, the United States has

tried and failed to enact a national

health insurance program.”

“At least six times since the

Depression, the United States has

tried and failed to enact a national

health insurance program.”

-- Lee & Paxman-- Lee & Paxman

“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”

“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”

-- Meadows, Richardson, Bruckman-- Meadows, Richardson, Bruckman

Flaws in Previous Attempts at Health Reform in AmericaFlaws in Previous Attempts at Health Reform in America

Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.

Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at <http://www.cpn.org/topics/health/healthquestion.html>.

Piecemeal approaches

Comprehensive strategies that are opposed by special interests

Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to

Observe the health system as a large, dynamic enterprise

Craft high-leverage strategies that can overcome policy resistance

Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)

Piecemeal approaches

Comprehensive strategies that are opposed by special interests

Assumption that healthcare dynamics are separate from other areas of public concern

Conventional analytic methods make it difficult to

Observe the health system as a large, dynamic enterprise

Craft high-leverage strategies that can overcome policy resistance

Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)

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

How Many Triangles Do You See?How Many Triangles Do You See?

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 CritiqueBoundary Critique

Misleading Framing AssumptionsMisleading Framing Assumptions

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

Stepwise progress will lead to system-wide improvement

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

What causes the behaviors we observe?What causes the behaviors we observe?

System-as-CauseSystem-as-Cause

“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.”

Beyond ScapegoatingBeyond Scapegoating

A Very Particular DistanceA Very Particular Distance

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

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

“The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned

with the action of a single individual, but not so far away

as to be ignorant of the internal pressures in the system.”

-- George Richardson

“The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned

with the action of a single individual, but not so far away

as to be ignorant of the internal pressures in the system.”

-- George Richardson

“A symbolic instrument made of a number of methods and techniques

borrowed from very different disciplines…The macroscope

filters details and amplifies that which links things together. It is not used to make things larger or smaller but to observe what is at once too great, too slow, and too

complex for our eyes.”

“A symbolic instrument made of a number of methods and techniques

borrowed from very different disciplines…The macroscope

filters details and amplifies that which links things together. It is not used to make things larger or smaller but to observe what is at once too great, too slow, and too

complex for our eyes.”

Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html

-- Joèel de Rosnay-- Joèel de Rosnay

Looking Through the MacroscopeLooking Through the Macroscope

What processes or phenomena in your work

might we need a macroscope to see?

What processes or phenomena in your work

might we need a macroscope to see?

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 AnalysisTools for Policy Analysis

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 DynamicsHealth System Dynamics

Adverse LivingConditions

GeneralProtection

Understanding Health as Public WorkUnderstanding Health as Public Work

SaferHealthierPeople

VulnerablePeople

Afflictedwithout

Complications

Afflicted withComplicationsBecoming

vulnerable


Becomingafflicted

Developingcomplications




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

World of Providing…

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

Medical and Public Health Policy

MANAGEMENT OFRISKS AND DISEASES

World of Transforming…

• Deprivation• Dependency• Violence• Discrimination• Environmental decay• Stress• Insecurity

By Strengthening…

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

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE


VulnerablePeople

Afflictedwithout

Complications


vulnerable

Becoming safer

and healthier

Becomingafflicted





Demand forresponse

GeneralProtection

TargetedProtection

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

PublicWork

Balancing Two Areas of EmphasisBalancing Two Areas of Emphasis

Testing Dynamic HypothesesTesting Dynamic Hypotheses

-- How can we learn about the consequences of actions in a system of this kind?-- Could the behavior of this system be analyzed using conventional epidemoiological methods (e.g., logistic or multi-level regression)?


VulnerablePeople

Afflictedwithout

Complications


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

Learning In and About Dynamic SystemsLearning In and About Dynamic Systems

Benefits of Simulation/Game-based Learning

Formal means of evaluating options

Experimental control of conditions

Compressed time

Complete, undistorted results

Actions can be stopped or reversed

Visceral engagement and learning

Tests for extreme conditions

Early warning of unintended effects

Opportunity to assemble stronger support

Benefits of Simulation/Game-based Learning

Formal means of evaluating options

Experimental control of conditions

Compressed time

Complete, undistorted results

Actions can be stopped or reversed

Visceral engagement and learning

Tests for extreme conditions

Early warning of unintended effects

Opportunity to assemble stronger support

Complexity Hinders

Generation of evidence (by eroding the conditions for experimentation)

Learning from evidence (by demanding new heuristics for interpretation)

Acting upon evidence (by including the behaviors of other powerful actors)

Complexity Hinders

Generation of evidence (by eroding the conditions for experimentation)

Learning from evidence (by demanding new heuristics for interpretation)

Acting upon evidence (by including the behaviors of other powerful actors)

Sterman JD. Learning from evidence in a complex world. AJPH 2006;96(3):505-514.

Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000.

“The complexity of our models vastly exceeds our ability to understand their implications without simulation."

-- John Sterman

“The complexity of our models vastly exceeds our ability to understand their implications without simulation."

-- John Sterman

Transforming the Future of Diabetes…Transforming the Future of Diabetes…

"Every new insight into Type 2 diabetes...

makes clear that it can be avoided--and that

the earlier you intervene the better. The real

question is whether we as a society are up to

the challenge...Comprehensive prevention

programs aren't cheap, but the cost of doing

nothing is far greater..."

Gorman C. Why so many of us are getting diabetes: never have doctors known so much about how to prevent or control this disease, yet the epidemic keeps on raging. how you can protect yourself. Time 2003 December 8. Accessed at http://www.time.com/time/covers/1101031208/story.html.

…in an Era of Epidemic Obesity

http://www.time.com/time/covers/1101031208/story.html

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

Simulations for Learning in Dynamic SystemsDiabetes Dynamics in an Era of Epidemic Obesity

Simulations for Learning in Dynamic SystemsDiabetes Dynamics in an Era of Epidemic Obesity

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.

Behavior Over Time (Experiments)Behavior Over Time (Experiments)Deaths per Population

0.0035

0.003

0.0025

0.002

0.0015

1980 1990 2000 2010 2020 2030 2040 2050

Time (Year)

Blue: Base run; Red: Clinical mgmt up from 66% to 90%;Green: Caloric intake down 4% (99 Kcal/day);Black: Clin mgmt up to 80% & Intake down 2.5% (62 Kcal/day)

Base

Downstream

Upstream

Mixed

Dynamic Hypothesis (Structure)Dynamic Hypothesis (Structure)

Setting Realistic ExpectationsHP 2010 Diabetes Objectives

Setting Realistic ExpectationsHP 2010 Diabetes Objectives

BaselineHP 2010 Target

Percent Change

Reduce Diabetes–related Deaths Among Diagnosed

(5-6)

8.8 per 1,000

7.8 -11%

Increase Diabetes Diagnosis (5-4)

68% 80% +18%

Reduce New Cases of Diabetes

(5-2)

3.5per 1,000

2.5 -29%

Reduce Prevalence of Diagnosed Diabetes

(5-3)

40 per 1,000

25 -38%

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

20

30

40

50

60

70

1980 1985 1990 1995 2000 2005 2010

Pe

op

le w

ith

dia

gn

ose

d d

iab

ete

s p

er

1,0

00

Reported Simulated

Status Quo

Meet Detection Objective (5-4)

Meet Onset Objective (5-2)

HP 2010 Objective (5-3)

HP 2000 Objective

History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results

History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results

A

B

C

D

E

F

G

H

I

The Simple Physics of DiabetesThe Simple Physics of Diabetes

It is impossible for any policy to reduce prevalence

38% by 2010!

People withUndiagnosed

Diabetes

People withDiagnosedDiabetes Dying from Diabetes

Complications

DiagnosedOnset

InitialOnset

People withNormal

GlycemicLevels

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

“Simulation is a third way of doing science. Like deduction, it

starts with a set of explicit assumptions. But unlike deduction,

it does not prove theorems. Instead, a simulation generates

data that can be analyzed inductively. Unlike typical induction,

however, the simulated data comes from a rigorously specified

set of rules rather than direct measurement of the real world.

While induction can be used to find patterns in data, and

deduction can be used to find consequences of assumptions,

simulation modeling can be used as an aid to intuition.”

“Simulation is a third way of doing science. Like deduction, it

starts with a set of explicit assumptions. But unlike deduction,

it does not prove theorems. Instead, a simulation generates

data that can be analyzed inductively. Unlike typical induction,

however, the simulated data comes from a rigorously specified

set of rules rather than direct measurement of the real world.

While induction can be used to find patterns in data, and

deduction can be used to find consequences of assumptions,

simulation modeling can be used as an aid to intuition.”

-- Robert Axelrod-- Robert Axelrod

Axelrod R. Advancing the art of simulation in the social sciences. In: Conte R, Hegselmann R, Terna P, editors. Simulating Social Phenomena. New York, NY: Springer; 1997. p. 21-40. <http://www.pscs.umich.edu/pub/papers/AdvancingArtofSim.pdf>.

A Third Branch of ScienceA Third Branch of Science

Syndemic Orientation

Enlarging the Scope of Public Health WorkEnlarging the Scope of Public Health Work“Public health imagination involves using science to expand the

boundaries of what is possible.”

-- Michael Resnick

“Public health imagination involves using science to expand the boundaries of what is possible.”

-- Michael Resnick

EpidemicOrientation

People inPlaces

EcologicalThinking

Governing Dynamics

Ca

us

al

Ma

pp

ing

Plausible Futures

DynamicModeling

Navigational Freedoms

De

mo

cra

tic

Pu

bli

c W

ork

“We are as confused as ever, but on a higher

level and about more important things.”

“We are as confused as ever, but on a higher

level and about more important things.”

Humor Consultants, Inc.Humor Consultants, Inc.

To Sum UpTo Sum Up

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

http://www.sp.uconn.edu/~geo101vc/Lecture22/sld030.htm

Systems ArchetypeSystems Archetype

Fixes That Fail

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

-

FixProblemSymptom

+

-

UnintendedConsequence

+

Delay+

+

In Public Health VocabularyIn Public Health Vocabulary

Fixes That Fail

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

+

TargetedResponse

HealthProblem -

-

Exclusions

+

Delay+

+

ExclusionsExclusions

Conceptual

Social

Organizational

Political

Disarray

Disorientation

Disparity & Disconnection

Together, these forces threaten increasing powerlessness of public health work

Scott JC. Seeing like a state: how certain schemes to improve the human condition have failed. New Haven ; London: Yale University Press, 1999.

"Certain forms of knowledge and control require a

narrowing of vision. The great advantage of such

tunnel vision is that it brings into sharp focus

certain limited aspects of an otherwise far more

complex and unwieldy reality. This very

simplification, in turn, makes the phenomenon at

the center of the field of vision more legible and

hence more susceptible to careful measurement

and calculation….making possible a high degree of

schematic knowledge, control, and manipulation."

"Certain forms of knowledge and control require a

narrowing of vision. The great advantage of such

tunnel vision is that it brings into sharp focus

certain limited aspects of an otherwise far more

complex and unwieldy reality. This very

simplification, in turn, makes the phenomenon at

the center of the field of vision more legible and

hence more susceptible to careful measurement

and calculation….making possible a high degree of

schematic knowledge, control, and manipulation."

There is Great Power in Focusing on One Problem at a Time

There is Great Power in Focusing on One Problem at a Time

-- James Scott-- James Scott

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Num

ber o

f Cig

aret

tes

Even the Greatest Gains are FragileEven the Greatest Gains are Fragile

Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.

“No improvements at all had been

made...open cesspools are still to

be seen...we have all the materials

for a fresh epidemic...the water-

butts were in deep cellars, close to

the undrained cesspool...The

overcrowding appears to increase."

“No improvements at all had been

made...open cesspools are still to

be seen...we have all the materials

for a fresh epidemic...the water-

butts were in deep cellars, close to

the undrained cesspool...The

overcrowding appears to increase."

Broad Street, One Year LaterBroad Street, One Year Later

SpecializationA Proven Problem Solving Approach

SpecializationA Proven Problem Solving Approach

Identify disease

Determine causes

Develop and test interventions

Implement programs and policies

Identify disease

Determine causes



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

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

Dangers of Getting Too SpecificDangers of Getting Too Specific

Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.

Conventional problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)

Conventional problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)

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 CritiqueBoundary Critique

How have you observed public health work changing?

What is driving those transformations?

Where is the field headed?

How have you observed public health work changing?

What is driving those transformations?

Where is the field headed?

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

Define the problem

Eliminate health disparities

Preparedness

Avoid activity limitation

Promote life satisfaction

Increase healthy days

Determine the cause

Social determinants of health

Built environment

Adverse childhood experiences

Genetics


Comprehensive community initiatives

Ecological perspectives

Inter-sector collaboration

Health impact assessments


Policy interventions

Community and systems change

Adaptation to local context

Increasing health care access

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, critical, practical)Concerned with creating and protecting values like health, dignity, 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, critical, practical)Concerned with creating and protecting values like health, dignity, security, satisfaction, justice, wealth, and freedom in both means and ends

A Field in TransitionA Field in Transition

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)

Locating categorical disease programs within a broader system of health protection

Constructing credible knowledge without comparison/control groups

Differentiating questions that focus on attribution versus contribution

Balancing trade-offs between short- and long-term effects

Avoiding the pitfalls of professonalism

Harnessing the power of citizen-led public work

Defining standards and values for judgment

Others…

Locating categorical disease programs within a broader system of health protection

Constructing credible knowledge without comparison/control groups

Differentiating questions that focus on attribution versus contribution

Balancing trade-offs between short- and long-term effects

Avoiding the pitfalls of professonalism

Harnessing the power of citizen-led public work

Defining standards and values for judgment

Others…

Serious Challenges for Planners and EvaluatorsSerious Challenges for Planners and Evaluators



“Model boundaries influence the recognition of feedback and

potential sources of environmental instability.”

-- Jay Forrest

“Model boundaries influence the recognition of feedback and

potential sources of environmental instability.”

-- Jay Forrest

Forrest J. Evolution and behavior of system structure: eight perspectives for examining a complex issue. 22nd International Conference of the System Dynamics Society; Oxford, England; 2004.

A syndemic orientation clarifies the dynamic and democratic character

of public health work

Exploring a Syndemic OrientationExploring a Syndemic OrientationStudy of innovations in public health work, with emphasis on transformations in concepts and methods

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 response system

Phase 1 (2001-2003): identify innovations and dilemmas; develop working definitions; explore relevant concepts and methods

Phase 2 (2004-2005): articulate the foundations of a syndemic orientation; work with leaders at the CDC and beyond to stimulate creativity, innovation, and reorient health protection ventures

Study of innovations in public health work, with emphasis on transformations in concepts and methods







Health

LivingConditions

Public Strength

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

How strong an influence do planned public health actions have on shaping

the conditions for health?

How strong an influence do planned public health actions have on shaping

the conditions for health?

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?

Goals Have a Nested StructureGoals Have a Nested StructureDisease Prevention

Prevent disease and injury

Disease Prevention

Prevent disease and injury

Imply that prerequisite conditions exist and that most, if not all, disease

prevention programs are effective simultaneously

Imply that prerequisite conditions exist and that most, if not all, disease

prevention programs are effective simultaneously

Health Promotion

Prolong length

Improve quality

Eliminate disparity

Enhance satisfaction

Health Promotion

Prolong length

Improve quality

Eliminate disparity

Enhance satisfaction

Public Health

Assure the conditions for health for all

Public Health

Assure the conditions for health for all

Stepwise or Synergy?Stepwise or Synergy?

0

100

0

100

Percent of Afflictions Under Control*

1850 2000 2100

Forces of change suggest one of these paths:

* For subgroups of the public; no afflictions have been controlled equitably except for smallpox

1950

%

%Year

“The time has come to close the book on infectious diseases. We have basically wiped out the infection in the United States.”

-- Surgeon General William Stewart (1967)

“The time has come to close the book on infectious diseases. We have basically wiped out the infection in the United States.”

-- Surgeon General William Stewart (1967)

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 and Creating ValueSolving Problems and Creating Value

-- Peter Senge-- Peter Senge

Identify place or population

Organize with residents/members to:

Identify afflictions and their relationships

Examine living conditions and why they differ

Devise beneficial system-wide policies

Build power to act

Direct the course of social change to assure the conditions for health for all

Expand to other places/populations, as necessary

Identify place or population

Organize with residents/members to:

Identify afflictions and their relationships

Examine living conditions and why they differ

Devise beneficial system-wide policies

Build power to act

Direct the course of social change to assure the conditions for health for all

Expand to other places/populations, as necessary

Steps in a Syndemic ApproachSteps in a Syndemic Approach

Syndemic Orientation

Network View Systems View

Navigational View

Formalizing an OrientationJoining Concepts and Methods

Formalizing an OrientationJoining Concepts and Methods

X Y

Connections Leverage Directed Public Work

Proximity Data Causal Data Directional Data

What links to what? What influences what? Where are we going?


Studying StabilityStudying Stability

Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. Accessed May 23, 2003 at <http://pespmc1.vub.ac.be/MACRBOOK.html>.

“There is no sociology of balance which is interested in the

social problems of a stabilized society…There is no

political science of equilibrium capable of enlightening

us on the means of exercising the democratic choice in a

society where short-term material gain would cease to be

the criterion of political success. ”

-- Joèel deRosnay

“There is no sociology of balance which is interested in the

social problems of a stabilized society…There is no

political science of equilibrium capable of enlightening

us on the means of exercising the democratic choice in a

society where short-term material gain would cease to be

the criterion of political success. ”

-- Joèel deRosnay

Seeking Syn-SolutionsSeeking Syn-Solutions

“If the health consequences of sprawl

represent a ‘syndemic’–a combination

of synergistic epidemics that

contributes to the population burden of

disease–then solutions may also

operate synergistically, ameliorating

several health problems.”

“If the health consequences of sprawl

represent a ‘syndemic’–a combination

of synergistic epidemics that

contributes to the population burden of

disease–then solutions may also

operate synergistically, ameliorating

several health problems.”

-- Howard Frumkin-- Howard Frumkin

Frumkin H. Urban sprawl and public health. Public Health Reports 2002;117(3):201-17.

“When X and Y affect each other, one cannot study the link between

X and Y and, independently, the link between Y and X and predict

how the system will behave. Only the study of the whole

system as a feedback system will lead to correct results."

“When X and Y affect each other, one cannot study the link between

X and Y and, independently, the link between Y and X and predict

how the system will behave. Only the study of the whole

system as a feedback system will lead to correct results."

-- System Dynamics Society-- System Dynamics Society

The Feedback ThoughtThe Feedback Thought

System Dynamics Society. What is system dynamics? System Dynamics Society, 2002. Accessed December 19, 2002 at <http://www.systemdynamics.org/>.

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

X Y

What happens if we shift from thinking about the variable-as-cause to the

system-as-cause?

What happens if we shift from thinking about the variable-as-cause to the

system-as-cause?

Argyris C. Actionable knowledge: design causality in the service of consequential theory. Journal of Applied Behavioral Science 1996;32(4):390-408.

Dent E. The interactional model: an alternative to the direct cause and effect construct for mutually causal organizational phenomena. Foundations of Science in press.

Richmond B. The "thinking" in systems thinking: seven essential skills. Waltham, MA: Pegasus Communications, 2000.

Beyond the Probable FutureBeyond the Probable Future

PossibleWhat may happen?

PlausibleWhat could happen?

ProbableWhat will likely happen?

PreferableWhat do we want to have happen?

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

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

-- Ciement Bezold

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 • 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• Navigational statistics

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

Policy DevelopmentPolicy Development

Explicit model building

Simulated experiments

What if…

What futures are plausible?

Real world action and observation

Explicit model building

Simulated experiments

What if…

What futures are plausible?

Real world action and observation

“The future is not to be predicted, but created.”

-- Arthur C. Clarke

“The future is not to be predicted, but created.”

-- Arthur C. Clarke

Patterns

Events

Analysis Process for Developing Policy

Analysis Process for Developing Policy

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

Curve-Fitting Models

Dynamic Models


Dynamic Models


Dynamic Models

Insight Generating

Capacity

Descriptive Realism

Mode Reproduction

Ability

Transparency

Relevance

Ease of Enrichment

Fertility

Formal Correspondence

with Data

Point Predictive Ability

Source: Randers JR. Elements of the System Dynamics Method. Cambridge Mass: Productivity Press, 1980. p. xx.


Dynamic Models

Seeing the Whole SystemSeeing the Whole System

Benefits

Places value on health and protection

Defines operational objectives (and timeframes)

Distinguishes types of work

Identifies needed information

Articulates a research agenda

Benefits

Places value on health and protection

Defines operational objectives (and timeframes)

Distinguishes types of work

Identifies needed information

Articulates a research agenda

Highlights Threats From

Imbalanced efforts

Short-sighted efforts

Adverse living conditions

Insufficient public work

Organizational disarray

Pitfalls of professionalism

Highlights Threats From

Imbalanced efforts

Short-sighted efforts

Adverse living conditions

Insufficient public work

Organizational disarray

Pitfalls of professionalism

Two Policy OrientationsTwo Policy OrientationsHealthy Public Policy Medical and Public Health Policy

Concerned chiefly with assuring healthful conditions

Concerned chiefly with preventing and alleviating affliction

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

Relies heavily on singular high technology solutions, widely applied

Expands to a broader synthesis, transcending sector boundaries

Confines analyses to the health sector

Future oriented Present oriented

Questions the givens Accepts the givens

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.

Light DW. The rhetorics and realities of community health care: the limits of countervailing powers to meet the health care needs of the twenty-first century. Journal of Health Politics, Policy, and Law 1997;22(1):105-45.

Effective Screening and Care Actually Increase Diagnosed Prevalence

Effective Screening and Care Actually Increase Diagnosed Prevalence

The combination of more detection and decreasing deaths leads to more people living with diagnosed diabetes

The combination of more detection and decreasing deaths leads to more people living with diagnosed diabetes

Diagnosed Diabetes Frac of Adult Population

0.15

0.1125

0.075

0.0375

0

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Dx diabetes fraction of adult popn : base fractionDx diabetes fraction of adult popn : 2010down fraction

Diagnosed Diabetes Frac of Adult Population

0.15

0.1125

0.075

0.0375

0

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Dx diabetes fraction of adult popn : base fractionDx diabetes fraction of adult popn : 2010down fraction

What Could We Have Been Thinking?What Could We Have Been Thinking?


Chronic Disease

People withDiagnosed

Chronic Disease Dying fromComplications

DiagnosingDisease


Developing Disease(incidence)

Generic Chronic Disease Structure


Infectious Disease

People withDiagnosed

Infectious Disease Dying fromComplications

DiagnosingDisease


Developing Disease(incidence)

Recovering fromDisease

Generic Infectious Disease Structure

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

Limits of Logic ModelsLimits of Logic Models

Logic models may look reasonable, but they can’t answer

Where to direct effort?When to act?How much effort will it take?What’s the expected benefit?When to expect change?What is the difference between various approaches?

Such questions can only be answered by experimenting, either through simulation or in the real-world

Logic models may look reasonable, but they can’t answer

Where to direct effort?When to act?How much effort will it take?What’s the expected benefit?When to expect change?What is the difference between various approaches?

Such questions can only be answered by experimenting, either through simulation or in the real-world

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

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

0.0035

0.003

0.0025

0.002

0.0015

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Diabetes-related death rate per year for adult popnBase

Mgmt90

Cal3

Mgmt85Cal2

0.0035

0.003

0.0025

0.002

0.0015

1980 1990 2000 2010 2020 2030 2040 2050Time (Year)

Diabetes-related death rate per year for adult popnBase

Mgmt90

Cal3

Mgmt85Cal2

Results from four simulation experiments using the Diabetes System Model

Results from four simulation experiments using the Diabetes System Model

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

“Even the best conceptual models can only be tested and improved by relying on the learning feedback through the real world…This feedback is very slow and often rendered ineffective by dynamic complexity, time delays, inadequate and ambiguous feedback, poor reasoning skills, defensive reactions, and the costs of experimentation. In these circumstances simulation becomes the only reliable way to test a hypothesis and evaluate the likely effects of policies."

“Even the best conceptual models can only be tested and improved by relying on the learning feedback through the real world…This feedback is very slow and often rendered ineffective by dynamic complexity, time delays, inadequate and ambiguous feedback, poor reasoning skills, defensive reactions, and the costs of experimentation. In these circumstances simulation becomes the only reliable way to test a hypothesis and evaluate the likely effects of policies."

-- John Sterman-- John Sterman

Why Simulate Proposed Policies?Why Simulate Proposed Policies?

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

AssuranceAssurance

Assure conditions that expand peoples’ freedoms to live healthfully and develop their creative potential

Powered by democratic public work, including that of citizen-professionals

Navigational perspective, guided by vision and values

Forward orientation

Adapts to constantly changing conditions

Breakdown means-end framing

Assure conditions that expand peoples’ freedoms to live healthfully and develop their creative potential

Powered by democratic public work, including that of citizen-professionals

Navigational perspective, guided by vision and values

Forward orientation

Adapts to constantly changing conditions

Breakdown means-end framing

“The path resounds to our footfall, but do we have it in ourselves to change direction?”

-- Peter Ustinov

“The path resounds to our footfall, but do we have it in ourselves to change direction?”

-- Peter Ustinov

"A bad solution is bad because it acts destructively upon the

larger patterns in which it is contained...because it is formed

in ignorance or disregard of them. A bad solution solves for a

single purpose or goal, such as increased production. And it

is typical of such solutions that they achieve stupendous

increase in production at exorbitant biological and social

costs…Good solutions recognize that they are part of a larger

whole. They solve more than one problem and don't create

new problems. A good solution should not enrich one person

by the distress or impoverishment of another."

"A bad solution is bad because it acts destructively upon the

larger patterns in which it is contained...because it is formed

in ignorance or disregard of them. A bad solution solves for a

single purpose or goal, such as increased production. And it

is typical of such solutions that they achieve stupendous

increase in production at exorbitant biological and social

costs…Good solutions recognize that they are part of a larger

whole. They solve more than one problem and don't create

new problems. A good solution should not enrich one person

by the distress or impoverishment of another."

-- Wendell Berry-- Wendell Berry

Berry W. Solving for pattern. In: The Gift of Good Land. San Francisco: North Point; 1981. p. 134-45.

Solving for PatternSolving for Pattern



The Syndemics Prevention NetworkThe Syndemics Prevention Network





Learning within innovative ventures

Comprehensive Community InitiativesPhilanthropy

Legacy InitiativesState Tobacco Settlements

Efforts to Eliminate Health Disparities Government and Philanthropy

Responses to Unjust Conditions Broad-based Citizen Organizations










Health

LivingConditions

PublicStrength



-- Sufi Saying


-- Sufi Saying











– Arthur Koestler


– Arthur Koestler



Health

LivingConditions

PublicStrength



Working in a New EraWorking in a New Era

“Today’s world, characterized by tremendous

globalization, connectivity, and speed poses

entirely new challenges. We have to be better

prepared to respond to the multiple public

health challenges, including those resulting

from an aging population, global threats of

disease and terrorism, obesity, and epidemic

threats of chronic diseases.”

“Today’s world, characterized by tremendous

globalization, connectivity, and speed poses

entirely new challenges. We have to be better

prepared to respond to the multiple public

health challenges, including those resulting

from an aging population, global threats of

disease and terrorism, obesity, and epidemic

threats of chronic diseases.”

-- Julie Gerberding-- Julie Gerberding

Centers for Disease Control and Prevention. CDC announces new goals and organizational design. Atlanta, GA; May 13, 2004. <http://www.cdc.gov/od/oc/media/pressrel/r040513.htm>.

What is the largest living organism?

What is the largest living organism?

Not Everything Meets the EyeLargest Living Organism

Not Everything Meets the EyeLargest Living Organism

Amos J. Fantastic fungus find: BBC News; August 7, 2000. <http://news.bbc.co.uk/1/hi/sci/tech/869808.stm>.

“You would not look at it and see a huge, looming

mushroom. Armillaria grows and spreads primarily

underground and the sheer bulk of this organism lies in

the earth, out of sight.”

“You would not look at it and see a huge, looming

mushroom. Armillaria grows and spreads primarily

underground and the sheer bulk of this organism lies in

the earth, out of sight.”

-- Jonathan Amos-- Jonathan Amos



Background on the Syndemics ProjectBackground on the Syndemics Project

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







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







Health

LivingConditions

Public Strength



-- Sufi Saying


-- Sufi Saying

Aspects of a syndemic orientation incorporate twenty-first century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of

adhering to this orientation remain largely unexplored.”

Aspects of a syndemic orientation incorporate twenty-first century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of

adhering to this orientation remain largely unexplored.”


But What is a Syndemic Orientation?

But What is a Syndemic 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.

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.






















Health

LivingConditions

PublicStrength



– Arthur Koestler


– Arthur Koestler




Efforts to Organize a System that Protects Population HealthDynamic interaction among multiple problems, problem solvers, and responses


Efforts to Organize a System that Protects Population HealthDynamic interaction among multiple problems, problem solvers, and responses

Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.


-- Sufi Saying


-- Sufi Saying

Continues Movement Away From Single-Issue Epidemiology

Continues Movement Away From Single-Issue Epidemiology

Community Health Centers (COPC)Health Systems AgenciesEnvironmental JusticeHealth Care For AllHealthy Cities/Healthy CommunitiesSocial InequalitiesTurning PointPerformance StandardsEcosystem HealthOthers….

Community Health Centers (COPC)Health Systems AgenciesEnvironmental JusticeHealth Care For AllHealthy Cities/Healthy CommunitiesSocial InequalitiesTurning PointPerformance StandardsEcosystem HealthOthers….

Sirianni C, Friedland L. Community health and civic organizing. In: Civic innovation in America: community empowerment, public policy, and the movement for civic renewal. Berkeley: University of California Press; 2001. p. 138-185.

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

Simulations for Learning in Dynamic SystemsThe Problem of Outside Assistance

Simulations for Learning in Dynamic SystemsThe Problem of Outside Assistance

Dynamic Hypothesis (Structure)Dynamic Hypothesis (Structure)

Behavior Over Time (Experiments)Behavior Over Time (Experiments)Affliction

prevalence& burden

Adverseliving

Publicstrength

R1

At-risk fraction

Afflictioncross-impacts

Effort to alleviate andprevent affliction

B1a

Effort to improveliving conditions

B1b

Effort to build public strength

B2

Social disparityR2c

R2b

R2a

R3a

Public work fraction

United efforts

Divided efforts

R3b

Outside assistance toalleviate and prevent

affliction

Outside assistanceto improve living

conditions

Outside assistanceto build public strength

Magnitude ofameliorative efforts

R4a

R4b B3b

B3a

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

conditions

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

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

Homer J, Milstein B. Optimal decision making in a dynamic model of poor community health. Proceedings of the 37th Hawaii International Conference on System Science; Big Island, Hawaii; January 5-8, 2004. Available at <http://csdl.computer.org/comp/proceedings/hicss/2004/2056/03/205630085a.pdf>.

Iterative Steps in System Dynamics Simulation Modeling

Iterative Steps in System Dynamics Simulation Modeling

Enact PolicyBuild power and

organize actors to establish chosen policies

Enact PolicyBuild power and

organize actors to establish chosen policies

Learn About Policy Consequences

Test proposed policies, searching for ones that

best govern change

Learn About Policy Consequences

Test proposed policies, searching for ones that

best govern change

Run Simulation Experiments

Compare model’s behavior to expectations and/or data to

build confidence in the model

Run Simulation Experiments

Compare model’s behavior to expectations and/or data to

build confidence in the model

Convert the Map Into a Simulation Model

Formally quantify the hypothesis using allavailable evidence

Convert the Map Into a Simulation Model

Formally quantify the hypothesis using allavailable evidence

Create a Dynamic Hypothesis Identify and map the

main causal forces that create the problem

Create a Dynamic Hypothesis Identify and map the

main causal forces that create the problem

Identify a Persistent Problem Graph its behavior

over time

Identify a Persistent Problem Graph its behavior

over time

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.

Average Number of Adult Unhealthy Days per Month

2

4

6

8

1993 1995 1997 1999 2001

Year

2005 2025 2050

Redirecting the Course of ChangeQuestions from System Dynamics and Social Navigation

Redirecting the Course of ChangeQuestions from System Dynamics and Social Navigation

14% increase

Zack MM, Moriarty DG, Stroup DF, Ford ES, Mokdad AH. Worsening trends in adult health-related quality of life and self-rated health–United States, 1993-2001. Public Health Reports 2004;119(September-October):493-505.

How?Why?

Where?

Who?

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

“Side Effects”

Feedback View

Goals

Environment

Decisions

Goals ofOthers

Actions ofOthers

“Side Effects”

Delay Delay

Delay

Delay

DelayDelay

Delay

Delay

Delay

Delay

Delay

Delay

Syndemics and the Interface Between Public Health, Systems Science, and Social Navigation Bobby Milstein Mid-America Regional Public Health Leadership.

Documents

public health work

new public health

future of public health

health crisis

local public health

journal of health care

merrill singer slide

social science