Syndemics Prevention Network Syndemics, System Science, and the Prospect of Navigating Health Futures Bobby Milstein Syndemics Prevention Network Centers.

Syndemics

Prevention Network

Syndemics, System Science, and the Prospect of

Navigating Health Futures

Bobby Milstein

Syndemics Prevention NetworkCenters for Disease Control and Prevention

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

Coordinating Center for Health PromotionCenters for Disease Control and Prevention

October 29, 2007

Syndemics

Prevention Network

Need to Connect Groups Focused on…

• Diseases/Disabilities arthritis, birth defects, cancer, diabetes, epilepsy, heart disease and stroke, obesity, oral health, mental health

• Risks tobacco, nutrition, physical activity, alcohol, sexual behavior, ACEs, racism, genetics

• Lifestagesinfants, children, adolescents, adults, older adults, reproductive age/pregnancy

• Places schools, communities, healthcare settings, global

• Sciences surveillance, prevention research, evaluation, social epidemiology, communications, economics, GIS, genomics, syndemics, well-being, quality of life

• National initiatives REACH, STEPS, WISEWOMAN, MS Delta, VERB

CoCHP Coordinates Many of Our Highest Priorities

Syndemics

Prevention Network

Imperatives for Protecting Health

Gerberding JL. Protecting health: the new research imperative. Journal of the American Medical Association 2005;294(11):1403-1406.

Typical Current State“Static view of problems that are studied in isolation”

Proposed Future State“Dynamic systems and syndemic approaches”

“Currently, application of complex systems theories or syndemic science to health protection challenges is in its infancy.”

-- Julie Gerberding

Syndemics

Prevention Network

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

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

-- Richard Rhodes

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

One Observer’s View

How is it directed?

How are innovators approaching the challenge of assuring more healthful and

equitable conditions?

Syndemics

Prevention Network

“The Healthy Hawaii Initiative is the only long-term, statewide program to implement a

social ecological approach to reduce obesity, increase physical activity, and

improve nutrition.”

Partnership for Prevention. Innovation in prevention awards announced. Washington, DC; October 26, 2006. <http://www.prevent.org/content/view/120/144/>.

Model VenturesHealthy Hawaii Initiative

-2%

0%

2%

4%

6%

8%

10%

Hawaii US

Percentage Change in Health IndicatorsHawaii and US, 1998-2003

Leisure TimeActivity

5+ Fruit/Vegper Day

Overweight/Obese Adults

Syndemics

Prevention Network

A Navigational View of Public Health Work

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

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007.

Where we want to go?

How do we prepare to get there?

Where do you want your children to live?

Where you do want to live?

Syndemics

Prevention Network


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

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

At first they all raised their hands but when they really

digested the question every single one of them put their

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

No one could answer that question. It was the most

uncomfortable moment of silence that I can remember…

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

have to participate in answering that question otherwise I

am not taking responsibility for the place I love and the

people I love.”

-- Nainoa Thompson


Syndemics

Prevention Network


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

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

At first they all raised their hands but when they really

digested the question every single one of them put their

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

No one could answer that question. It was the most

uncomfortable moment of silence that I can remember…

That was the defining moment for me. I recognized

that I have to participate in answering that question

otherwise I am not taking responsibility for the place I

love and the people I love.”

-- Nainoa Thompson


Syndemics

Prevention Network

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

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

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

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

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

-- William James

Pragmatism• Begins with a response to a perplexity or injustice

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

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

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

Syndemics

Prevention Network

Seeing Syndemics

A syndemic orientation clarifies the dynamic and democratic character

of public health work

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

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

-- Sufi Saying

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

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

– mutually reinforcing health problems

– health status and living conditions

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

Health

LivingConditions

Power toAct

“Health Policy”

“Social Policy”

“Citizen-ship”

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

Syndemics

Prevention Network

Exploring the Dynamic and Democratic Characterof Public Health Work

PUBLIC HEALTH WORK

InnovativeHealth

Ventures

UNDERSTANDING CHANGESystems Science

• What causes population health problems?

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

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

SETTING DIRECTIONPublic Health

What are health leaderstrying to accomplish?

GOVERNING MOVEMENTSocial Navigation

Directing Change

Charting Progress

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

• How are conditions changing?• In which directions?

Syndemics

Prevention Network

Changing (and Accumulating) Views of Population Health

What Accounts for Poor Population Health?

• God’s will

• Humors, miasma, ether

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

• Single disease, single cause (e.g., germ theory)

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

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

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

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

1880

1950

1960

1980

2000

1840

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

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

Syndemics

Prevention Network

Epi·demic

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

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

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

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

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

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

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

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

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

-- Gil Elliot

Syndemics

Prevention Network

Syn·demic

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

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

Confounding

Connecting*

Synergism

Syndemic

Events

System

Co-occurring

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

Syndemics

Prevention Network

Time Series Models

Describe trends

Multivariate Stat Models

Identify historical trend drivers and correlates

Patterns

Structure

Events

Increasing:

• Depth of causal theory

• Robustness for longer-term projection

• Value for developing policy insights

• Degrees of uncertainty

• Leverage for change

Increasing:

• Depth of causal theory

• Robustness for longer-term projection

• Value for developing policy insights

• Degrees of uncertainty

• Leverage for changeDynamic Simulation Models

Anticipate new trends, learn about policy consequences,

and set justifiable goals

Tools for Policy Planning & Evaluation

Syndemics

Prevention Network

• PossibleWhat may happen?

• PlausibleWhat could happen?

• ProbableWhat will likely happen?

• PreferableWhat do we want to have happen?

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

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

-- Clement Bezold

Seeing Beyond the Probable

Syndemics

Prevention Network

Re-Directing the Course of ChangeQuestions of Social Navigation

Prevalence of Diagnosed Diabetes, United States

0

10

20

30

40

1980 1990 2000 2010 2020 2030 2040 2050

Mill

ion

pe

op

le

HistoricalData

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

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

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

Markov Forecasting Model

Trend is not destiny

How?

Why?

Where?

Who?

What?

Syndemics

Prevention Network

Broad Dynamics of the Health Protection Enterprise

Prevalence of Vulnerability, Risk, or Disease

Time

HealthProtection

Efforts

-

B

Responsesto Growth

Resources &Resistance

-B

Obstacles

Broader Benefits& Supporters

R

ReinforcersPotentialThreats

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

basic features of this dynamic and democratic system

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

basic features of this dynamic and democratic system

Size of the Safer, Healthier

Population-

Prevalence of Vulnerability,

Risk, or Disease

B

Taking the Toll

0%

100%

R

Drivers ofGrowth

Values for Health & Equity

Syndemics

Prevention Network

There Have Been Remarkable Successes in Redirecting the Course of Change

600

500

400

200

100

501950 1960 1970 1980 1990 1995

Ag

e-a

dju

ste

d D

eath

Rat

e p

er 1

00,

000

Po

pu

lati

on

1955 1965 1975 1985

300

700

Peak Rate

Rate if trend continued

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.

Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke -- United States, 1900-1999. MMWR 1999;48(30):649-656. Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm>

Actual Rate

Overall Decline is Linked to…

• Reduced smoking

• Changes in diet

• Better diagnosis and treatment

• More heath services utilization

Overall Decline is Linked to…

• Reduced smoking

• Changes in diet

• Better diagnosis and treatment

• More heath services utilization

684,000 fewer deaths in 1998 alone

684,000 fewer deaths in 1998 alone

Syndemics

Prevention Network

Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs

0

4

8

12

16

200420001996199219881984198019761972196819641960

Consumer price index (CPI-U) relative to 1960

Healthcare

Total economy

Consumer Price Indices for Healthcare and the General Economy United States, 1960-2004 (1960=1)

Syndemics

Prevention Network

500,000

750,000

1,000,000

1,250,000

1,500,000

1,750,000

2,000,000

2,250,000

2,500,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

American Bankruptcy Institute. Bankruptcy filing statistics: non-business filings. Alexandria, VA: American Bankruptcy Institute; October, 2007. <http://www.abiworld.org/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=48428>.

Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Affairs 2005:hlthaff.w5.63. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1

Fox M. Half of Bankruptcy Due to Medical Bills -- U.S. Study: Reuters; February 2, 2005.

Total Personal Bankruptcy Filings, United States, 1994-2006

Healthcare Cost is Also the Leading Driver of Personal Bankruptcy

61% of the filers surveyed failed to seek needed medical treatments

61% of the filers surveyed failed to seek needed medical treatments

Syndemics

Prevention Network

4

5

6

7

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

17% increase

Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2007. Accessed October 23, 2007 at <http://apps.nccd.cdc.gov/HRQOL/index.asp>.

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(5):493-505.

Average Number of Adult Unhealthy Days per Month, United States, 1993-2006

Worsening Trend in Summary Measures of Population Health

Syndemics

Prevention Network

Entrenched Inequities

Syndemics

Prevention Network

Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med 2006;3(9). Available at <http://medicine.plosjournals.org/archive/1549-1676/3/9/pdf/10.1371_journal.pmed.0030260-L.pdf>

Entrenched Inequities

Life Expectancy at Birth in the Eight Americas (1982-2001)

Syndemics

Prevention Network

A Complementary Science of Relationships

• Efforts to Reduce Population Health ProblemsProblem, problem solver, response

• Efforts to Organize a System that Assures Healthful Conditions for All Dynamic interaction among multiple problems, problem solvers, and responses

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

Institute of Medicine. The future of the public's health in the 21th century. Washington, DC: National Academy Press, 2002.

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

Syndemics

Prevention Network

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

-- Joèl de Rosnay

Looking Through the Macroscope

Syndemics

Prevention Network

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

How Many Triangles Do You See?

Syndemics

Prevention Network

Boundary Judgments(System of Reference)

Observations(Facts)

Evaluations(Values)

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

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

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

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

-- Albert Einstein

Syndemics

Prevention Network

The Weight of Boundary Judgments

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

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


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

Syndemics

Prevention Network

Implications for Policy Planning and Evaluation

Insights from the Overview Effect

• Maintain a particular analytic distance

• Not too close to the details, but not too far as be insensitive to internal pressures

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

• Structure determines behavior

• Potential to avoid scapegoating or lionizing


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

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

Syndemics

Prevention Network

Centers for Disease Control and Prevention. 150th anniversary of John Snow and the pump handle. MMWR 2004;53(34):783. Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5334a1.htm>

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


Broad Street, One Year Later

John Snow Heroic Success or Cautionary Tale?

“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."

Syndemics

Prevention Network

Galea S. Macrosocial determination of population health: the example of urbanization. NCEH/ATSDR Director's Science Seminar Series; Atlanta, GA: Centers for Disease Control and Prevention; February 7, 2007.

John Snow Heroic Success or Cautionary Tale?

Syndemics

Prevention Network

What Do These Observations Having in Common?

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

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

• Low tar and low nicotine cigarettesLead to greater carcinogen intake

• Fad dietsProduce diet failure and weight gain

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

• Antibiotic & pesticide useStimulate resistant strains

• Air-conditioning useRaises neighborhood heat

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

• War on drugs Raises price and attracts supply

• Suppressing dissent Inspires radicalization and extremism

Syndemics

Prevention Network

Policy Resistance is…

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

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

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

-- Meadows, Richardson & Bruckmann

Defining Keywords

Syndemics

Prevention Network

Systems Archetype

“Fixes that Fail”

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

Fix

+

ProblemSymptom

-

UnintendedConsequence

+

Delay

+

-B

+R

Characteristic Behavior:

Better before Worse

Syndemics

Prevention Network

“Fixes that Fail” in Public Health Vocabulary

The Risk of Targeted Interventions

+

HealthProblem -

-

Exclusions

+

+

TargetedResponseB

Delay+R

What issues tend to be excluded?

Syndemics

Prevention Network

Some Categories of Exclusions

Conceptual

Social

Organizational

Political

Disarray

Disorientation

Disparity & Disconnection

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

Syndemics

Prevention Network

Seeking High-Leverage Policies

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

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

-- Archimedes

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

Syndemics

Prevention Network

Syndemic Orientation

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

boundaries of what is possible.”

-- Michael Resnick

EpidemicOrientation

Problems Among

People inPlaces

Over Time

BoundaryCritique

Governing Dynamics

Ca

us

al

Ma

pp

ing

Plausible Futures

DynamicModeling

Navigational Freedoms

De

mo

cra

tic

Pu

bli

c W

ork

Syndemics

Prevention Network

Time 100: the people who shape our world. Time Magazine 2004 April 26.

Gerberding JL. CDC: protecting people's health. Director's Update; Atlanta, GA; July, 2007.

Gerberding JL. Health protectionomics: a new science of people, policy, and politics. Public Health Grand Rounds; Washington, DC: George Washington University School of Public Health and Health Services; September 19, 2007. Available at <http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2349>

Centers for Disease Control and Prevention. Health system transformation: Office of Strategy and Innovation; September 28, 2007. <http://intradev.cdc.gov/od/osi/policy/healthSystems_overview.htm>.

Working Harder to AchieveHealth Protection…Health Equity

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Prevention Network

The Dynamics of Upstream and Downstream: Why is So Hard for the Health System to Work Upstream?

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

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

Centers for Medicaid and Medicare Services. National health expenditures. Centers for Medicaid and Medicare Services, 2006. <http://www.cms.hhs.gov/NationalHealthExpendData/>.

Levi J, Trust for America's Health. Shortchanging America's health 2006: a state-by-state look at how federal public health dollars are spent. Washington, DC: Trust for America's Health, 2006.

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

Jackson DJ, Valdesseri R, CDC Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 2004. <http://intranet.cdc.gov/od/futures/wrkgroup/stage_i/hswg.htm>

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Prevention Network

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

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention

TargetedProtection

Society's HealthResponse

Demand forresponse

PublicWork

SaferHealthierPeople Becoming

vulnerable

Becoming saferand healthier

VulnerablePeople Becoming

afflicted

Afflictedwithout

Complications Developingcomplications

Afflicted withComplications

Dying fromcomplications

Health System Dynamics

Adverse LivingConditions

GeneralProtection

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

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

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

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

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

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

-- Julie Gerberding

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Prevention Network

Prerequisite 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. Available at <http://www.who.int/hpr/archive/docs/ottawa.html>.

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

Peace

Shelter

Education

Food

Income

Stable eco-system

Sustainable resources

Social justice and equity

Syndemics

Prevention Network

Seeing Conditions as Freedoms

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

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

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


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

Syndemics

Prevention Network

Balancing Two Major Areas of Emphasis

SaferHealthierPeople

VulnerablePeople

Afflictedwithout

ComplicationsAfflicted with

ComplicationsBecomingvulnerable


Becomingafflicted

Developingcomplications




Demand forresponse

GeneralProtection

TargetedProtection

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

Public Work

World of Providing…

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

Medical and Public Health Policy

MANAGEMENT OF DISEASES AND RISKS

World of Transforming…

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

By Strengthening…

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

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE


Syndemics

Prevention Network

Understanding Health as Public Work

SaferHealthierPeople

VulnerablePeople

Afflictedwithout

Complications

Afflicted withComplicationsBecoming

vulnerable


Becomingafflicted





Demand forresponse

GeneralProtection

TargetedProtection

PrimaryPrevention

SecondaryPrevention

TertiaryPrevention

-

Public Work-

Vulnerable andAfflicted People

Fraction of Adversity,Vulnerability and AfflictionBorne by Disadvantaged

Sub-Groups (Inequity)

-

PublicStrength

Citizen Involvementin Public Life

Social Division

Syndemics

Prevention Network

Refining the Hypothesis

Incorporating Public vs. Professional Concern

Syndemics

Prevention Network

Health System DynamicsIncorporating Public vs. Professional Concern

Safer,Healthier

Population

VulnerablePopulation

Becomingvulnerable

Becoming nolonger vulnerable

Afflictedwithout

ComplicationsBecomingafflicted



Dying fromComplications


Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.

Syndemics

Prevention Network

Health System Dynamics Incorporating Public vs. Professional Concern

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Downstreamwork

Professionalconcern



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onprogression

-

Effect oncomplications

-

TertiaryPrevention

SecondaryPrevention

Downstreamwork

Professionalconcern



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout






-


-

TertiaryPrevention

SecondaryPrevention

Vulnerable andAfflicted Population

Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

Publicwork



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-

Effect on livingconditions

Effect onvulnerabilityreduction

GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

-

Publicwork



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-

Citizen Involvementand Organizing

SocialDivision

-

Publicwork



Syndemics

Prevention Network


Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-


SocialDivision

-

Publicwork

Institutional/organizationalemphasis on disease rather

than vulnerability

-



Syndemics

Prevention Network

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

Initial Observations

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

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

• Because of their role as providers of downstream services, health professionals do not respond to vulnerability and social inequity for it own sake, in the way that ordinary citizens often do

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



Syndemics

Prevention Network

Mechanic D, Tanner J. Vulnerable people, groups, and populations: societal view. Health Affairs 2007;26(5):1220-1230.

Vulnerability is Becoming an Increasingly Prominent Focus of Concern

“Vulnerability, the susceptibility to

harm, results from…developmental

problems, personal incapacities,

disadvantaged social status,

inadequacy of interpersonal networks

and supports, degraded

neighborhoods and environments, and

the complex interactions of these

factors over the life course.”

-- Mechanic & Tanner

Syndemics

Prevention Network

Evaluating Dynamic, Democratic Policies

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

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention


Upstreamwork

Downstreamwork

Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-


SocialDivision

-

Publicwork

Institutional/organizationalemphasis on disease rather

than vulnerability

-

Syndemics

Prevention Network

System Dynamics Was Developed to Address Problems Marked By Dynamic Complexity

Good at Capturing

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

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

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

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

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

• Differences or inconsistencies in goals/values among stakeholders


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

Origins • Jay Forrester, MIT, Industrial Dynamics,

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

• Public policy applications starting late 1960s

• Population health applications starting mid-1970s

Syndemics

Prevention Network

An (Inter) Active Form of Policy Planning/Evaluation

System Dynamics is a methodology to…

• Map the salient forces that contribute to a persistent problem;

• Convert the map into a computer simulation model, integrating the best information and insight available;

• Compare results from simulated “What If…” experiments to identify intervention policies that might plausibly alleviate the problem;

• Conduct sensitivity analyses to assess areas of uncertainty in the model and guide future research;

• Convene diverse stakeholders to participate in model-supported “Action Labs,” which allow participants to discover for themselves the likely consequences of alternative policy scenarios

Syndemics

Prevention Network

Model Uses and Audiences

• Set Better Goals (Planners & Evaluators)

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

• Support Better Action (Policymakers)

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

• Develop Better Theory and Estimates (Researchers)

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

Syndemics

Prevention Network

Learning In and About Dynamic Systems

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

Real World

InformationFeedback

Decisions

MentalModels

Strategy, Structure,Decision Rules

• Selected• Missing• Delayed• Biased• Ambiguous

• Implementation• Game playing• Inconsistency• Short term

• Misperceptions• Unscientific• Biases• Defensiveness

• Inability to infer dynamics from

mental models

• Known structure • Controlled experiments• Enhanced learning

Virtual World

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


Syndemics

Prevention Network

Selected CDC Projects Featuring System Dynamics Modeling (2001-2007)

• Syndemics Mutually reinforcing afflictions

• Diabetes In an era of rising obesity

• ObesityLifecourse consequences of changes in caloric balance

• Infant HealthFetal and infant morbidity/mortality

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

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

• Grantmaking ScenariosTiming and sequence of outside assistance

• Upstream-Downstream EffortBalancing disease treatment with prevention/protection

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

• Chronic Illness DynamicsHealth and economic scenarios for downstream and upstream reforms

Syndemics

Prevention Network

Preventing and Managing Risk Factors for Heart Disease and Stroke

Modeling the Local Dynamics of Cardiovascular Health

Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modeling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease (in press).

Syndemics

Prevention Network

ContributorsCore Design Team• CDC: Michele Casper, Rosanne Farris, Darwin Labarthe,

Marilyn Metzler, Bobby Milstein, Diane Orenstein• Austin: Cindy Batcher, Karina Loyo, Ella Pugo, Rick

Schwertfeger, Adolfo Valadez, Josh Vest, • NIH: David Abrams, Patty Mabry• Consultants: Jack Homer, Justin Trogdon, Kristina Wile

Organizational Sponsors• Austin/Travis County Health and Human Services Department• CDC Division for Heart Disease and Stroke Prevention• CDC Division of Adult and Community Health• CDC Division of Nutrition, Physical Activity, and Obesity• CDC Division of Diabetes Translation • CDC Office on Smoking and Health• CDC NCCDPHP Office of the Director• Indigent Care Collaborative (Austin, TX)• NIH Office of Behavioral and Social Science Research• RTI International• Sustainability Institute• Texas Department of Health

Syndemics

Prevention Network

Better understand and govern

trends in cardiovascular health

at a local level by modeling

the likely consequences of

alternative intervention strategies

Project Purpose

Syndemics

Prevention Network

Action Framework for a Comprehensive and Coordinated Public Health Strategy to Prevent Heart Disease and Stroke

Syndemics

Prevention Network

Crafting Effective Intervention Strategies for Upstream Prevention in Context

• Concentrate on “upstream” challenge of minimizing risk, rather than the better understood “downstream” task of post-event care

• Local conditions affect people’s health status and their responses to perceived problems

• Local social and physical factors may be critical when characterizing the history—and plausible futures—of cardiovascular disease in a given city or region

• These aspects of local context are difficult to measure and too often excluded when planning and evaluating policies or programs

Syndemics

Prevention Network

Project Tasks

Develop a general causal framework for thinking about CVD risk factors and contextual factors

Develop a national-level simulation model of CVD risk factors, with projected outcomes based on AHA 2003 estimates and Framingham risk calculator

Learn about and quantify key contextual factors in Austin as well as local interventions attempted and planned

Add contextual factors and calibrate the simulation model

• Evaluate alternative interventions in terms of CV events and costs

Syndemics

Prevention Network

UTILIZATION OF SERVICES• Behavioral change

• Social support

• Mental health

• Preventive health

Modified AndersonRisk Calculator

RISK FACTOR ONSET,PREVALENCE & CONTROL

• Hypertension

• High cholesterol

• Diabetes

• Obesity

• Smoking

• Secondhand smoke

• Air pollution exposure

ESTIMATED FIRST-TIME FATALAND NON-FATAL CVD EVENTS

• CHD (MI, Angina, Cardiac Arrest)

• Stroke

• Total CVD (CHD, Stroke, CHF, PAD)

COSTS (CVD & NON-CVD)ATTRIBUTABLE TO RISK FACTORS

LOCAL CONTEXT• Eating & activity options

• Smoking policies

• Socioeconomic conditions

• Environmental policies

• Health care options

• Support service options

• Media and events

Local capacity for leadership & organizing

LOCAL ACTIONS

NUTRITION, PHYSICALACTIVITY & STRESS

• Salt intake• Bad fats intake• Fruit/Vegetable intake• Net caloric intake• Physical activity• Chronic stress

Preventing and Managing Risk Factors for CVDSector Diagram

DRAFT: October, 2007

Syndemics

Prevention Network

Preventing and Managing Risk Factors for CVDCore Structure

High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert

Smoking and equivalentsecondhand smoke and air

pollution exposure

SecondhandsmokeSmoker

First-time CVevents and deaths

Diabetes


Syndemics

Prevention Network

Preventing and Managing Risk Factors for CVDCore Structure

High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure



One-year costs fromfirst-time CV and other

risk factor complicationsDiabetes


Syndemics

Prevention Network

Preventing and Managing Risk Factors for CVDPolicy Pathways

High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure




risk factor complications

Access to quitservices

Air pollutionexposure

Anti tobaccopolicy

Clean indoorair policies

Diabetes


Syndemics

Prevention Network


High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure


Diagnosis andcontrol





Access toprimary care


Effectiveness ofprimary care

Anti tobaccopolicy


Diabetes


Syndemics

Prevention Network


High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure


Healthinessof diet

Extent ofphysical activity






Access to healthyfood options

Access to physicalactivity options

Access to weightloss/maintenance

servicesAccess to

primary care



Anti tobaccopolicy


Diabetes


Syndemics

Prevention Network


High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure


Healthinessof diet


Chronicstress






Access to mentalhealth services

Sources of chronicstress (unalleviated by

social supports)




servicesAccess to

primary care



Anti tobaccopolicy


Diabetes


Syndemics

Prevention Network



High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure


Healthinessof diet


Chronicstress








social supports)




services



Effectiveness ofchronic care

system

Marketing ofhealthy behaviors

Anti tobaccopolicy


Diabetes

Syndemics

Prevention Network



High cholesterol

Hypertension

Smoking

Obesity

Notobese

Obese

Not highcholest

Highcholest

Nondiab

Diabetic

Nonsmoker

Nonhypt

Hypert


pollution exposure


Healthinessof diet


Chronicstress








social supports)




services



Effectiveness ofchronic care

system

Marketing ofhealthy behaviors

Anti tobaccopolicy


Diabetes

Marketing of health& social services

Syndemics

Prevention Network

Assembling Available Information

Information Sources Relevant Model Parameters

U.S. Census & Vital Statistics

• Population • Birth rate• Net immigration rate • Death rate

American Heart Association• CVD events• CVD deaths• CVD post-event prevalence

National Health and Nutrition Examination Survey

• Risk factor prevalences• Fractions diagnosed and undiagnosed• Extent to which "control" reduces CVD risk• Numerous age and gender distinctions

Medical Expenditure Panel Survey & National Health Interview Survey

(Linked)

• Inpatient hospital costs and workdays lost due to non-CVD consequences of CVD risk factors

Bureau of Labor Statistics • Working fraction of population

Behavioral Risk Factor Surveillance System

• Access to healthy food options• Unhealthy diet• Access to physical activity options• Inadequate physical activity• Access to regular primary care • Chronic stress • Trying to lose weight• Trying to quit smoking• Workplaces allowing smoking

Syndemics

Prevention Network

Assembling Available Information

Information Sources Relevant Model Parameters

Professional Literature

• Anderson risk calculator• Prevalence ratios relating obesity with BP, cholesterol, and diabetes• Relative risks from inadequate PA for obesity, diabetes, and high BP• Smoking quit rates• Becoming non-obese rates• PAD prevalence and deaths• Average US air pollution level• Hours spent outdoors per day• Fraction of nonsmokers living with smokers• Effect of smoking quit services on quit rate• Relative risk for CVD from secondhand smoke• Relative risk for CVD from air pollution• Impact of smoking on obesity• Value per lost workday• Direct and indirect costs of CVD events

Austin Team Questionnaire

• Access to local weight loss, mental health, and smoking quit services• Use of local primary care, weight loss, mental health, and smoking quit services• Impact of mental health services on stress• Impact of local social marketing on diet, PA, smoking• Impact of local weight loss services on becoming non-obese • Impact of primary care on diagnosis and control of high BP, cholesterol, diabetes• Relative risks from inadequate PA for high cholesterol, stress• Relative risks from chronic stress for high BP, high cholesterol, smoking initiation, quits, obesity• Relative risks from poor diet for high BP, high cholesterol, obesity

Syndemics

Prevention Network

Developing a Base Case or “Status Quo” ScenarioAssumptions for Input Time Series through 2040

• A plausible and straightforward scenario

– Assume no further changes in contextual factors affecting risk factor prevalences

– Any changes in prevalences after 2000 are due to “bathtub” adjustment process and population aging

– Provides an easily-understood basis for comparisons

• Result: Past trends continue after 2000, but decelerate and level off

– Increasing obesity, high BP, and diabetes

– Decreasing smoking

– High cholesterol mixed bag, flat overall

1-Year Costs of All CV & RF Complications per preCVD Popn800

600

400

200

01990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

Time (Year)

dol

lars

/(Y

ear*

per

son)

No Further Changes in Drivers

No Further Changes in Drivers

Syndemics

Prevention Network

0%

5%

10%

15%

20%

25%

30%

35%

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

Year

Pe

rce

nt

Obese Fraction of Total Pre-CVD Population

0%

5%

10%

15%

20%

25%

30%

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

Year

Per

cen

t

Smoking Fraction of Total Pre-CVD Population

0%

5%

10%

15%

20%

25%

30%

35%

40%

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

Year

Pe

rce

nt

High BP Fraction of Total Pre-CVD Population

-2%

8%

18%

28%

38%

48%

58%

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

Year

Pe

rce

nt

High Cholesterol Fraction of Total Pre-CVD Population

0%

2%

4%

6%

8%

10%

12%

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

Year

Pe

rce

nt

Diabetes Fraction of Total Pre-CVD Population

Some Examples of Historical Reproduction

Syndemics

Prevention Network

CVD Risk Factors Directly Affected

Policy InterventionsIncrease (or Decrease)…

High Blood Pressure

High cholesterol

DiabetesSmoking1 & equivalent

Obesity

Access to primary care2 √ √ √

Effectiveness of primary care √ √ √

Access to smoking quit services √

Anti-tobacco policy √

Clean indoor air policies √

Air pollution exposure √

Access to weight loss/maintenance services

√

Access to healthy food options √ √ √

Access to physical activity options √ √ √ √

Sources of chronic stress (poverty, crime, discrimination)

√ √ √ √ 3

Access to mental health services4 √ √ √ √ 3

Marketing healthy behaviors5 √ √ √ √ √

Marketing health/social services6 √ √ √ √ √

1 Reductions in smoking may lead to some increase in eating and obesity; 2 Primary care improves diagnosis and control of affected conditions; 3 Due to stress-eating; 4 Affects chronic stress; 5 Affects nutrition, PA, and smoking; 6 Affects primary care as well as services for weight loss/maintenance, smoking cessation, and mental health

Exploring “What If…” Scenarios

Syndemics

Prevention Network

700

625

550

475

400

Do

lla

rs/(

Ye

ar*

pe

rso

n)

1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040

BasePrimary Care Access 1Primary Care Effectiveness 1Diet & PA Access 1Diet & PA Access 1 + Social Marketing 1Access + Marketing + Effective Care

1-Year Costs of All Cardiovascular Events & Risk Factor Complications Per Capita Among the pre-CVD Population

Prototype Simulation ScenariosTests of Extreme Conditions

Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at <http://web.mit.edu/jsterman/www/All_Models.html>

Sterman J. A sketpic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229. <http://web.mit.edu/jsterman/www/Skeptic%27s_Guide.html>

“All models are wrong, some are useful.”

-- George Box

“All models are wrong, some are useful.”

-- George Box

Syndemics

Prevention Network

Simulations for Learning in Dynamic Systems

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


Multi-stakeholder Dialogue

Dynamic Hypothesis (Causal Structure)

X Y

Plausible Futures (Policy Experiments)

Syndemics

Prevention Network

Syndemic Orientation

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

boundaries of what is possible.”

-- Michael Resnick

EpidemicOrientation

Problems Among

People inPlaces

Over Time

BoundaryCritique

Governing Dynamics

Ca

us

al

Ma

pp

ing

Plausible Futures

DynamicModeling

Navigational Freedoms

De

mo

cra

tic

Pu

bli

c W

ork

Syndemics

Prevention Network

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

and debate its nuances, but most of them couldn’t organize a block party.”

-- Ed Chambers

Power Has to be Organized

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

Syndemics

Prevention Network

“The challenge of involving the community is

especially difficult if one has been trained, as

I have been trained, to be an arrogant, elitist

prima donna. I am the ‘expert,’ after all, and I

help people by sharing my expertise.”

-- Len Syme

Syme SL. Social determinants of health: the community as an empowered partner. Preventing Chronic Disease 2004: 1(1) Accessed December 15, 2003. Available from: http://www.cdc.gov/pcd/issues/2004/jan/syme.htm

Boyte HC. Professions as public crafts. Wingspread Conference on New Information Commons; Racine, WI: Center for Democracy and Citizenship; 2000. Available at <http://www.publicwork.org/pdf/workingpapers/Public%20crafts.pdf>

Boyte HC, Kari NN. Turning our jobs into public work. In: Boyte HC, Kari NN, editors. Building America: the Democratic Promise of Public Work. Philadelphia: Temple University Press; 1996. p. 164-188.

Becoming a Professional Often Implies Standing Outside of the Public

Innovators in higher education tend to view professions as “public crafts” and emphasize

the democratic skills of “citizen-professionals”

Innovators in higher education tend to view professions as “public crafts” and emphasize

the democratic skills of “citizen-professionals”

Syndemics

Prevention Network

Growth of Citizen Actors

“Almost everyone knows about the

explosion of the dot-coms…but millions

have still not heard the big story:

the worldwide explosion of dot-orgs.

More people today have the freedom,

time, wealth, health, exposure, social

mobility, and confidence to address

social problems in bold new ways.”

-- David Bornstein

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

Number of Public Service GroupsRegistered with IRS

0

500,000

1,000,000

1989 1998

Nu

mb

er

Re

gis

tere

d

60%

Syndemics

Prevention Network

Public work is sustained, visible, serious effort by a diverse mix of ordinary people that creates things of lasting civic or public significance.

Mitchell Siporin. Jane Addams memorial. Illinois Federal Art Project, WPA, 1936. Fine Arts Collection, General Services Administration.

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

What Exactly is Public Work?

Syndemics

Prevention Network

• CDC’s credibility and effectiveness rest on more than scientific excellence

• The agency’s reputation also stems from a widespread perception that CDC staff are working to protect us all: that it is a people’s institution

• Leadership for system change, both upstream and down, involves inspiring (or confronting) others to establish safer, healthier conditions in their own spheres of influence

• At the same time, CDC is among the most trusted sources for defining which conditions are safer and healthier, and for charting progress (past and plausible futures)

• These separate aspects of navigation—directing change and charting progress—are easily confused

CDC’s Strength Lies in Wayfinding for HealthThrough Public Work

Harris Interactive. CDC, FAA, NIH, FDA, FBI and USDA get the highest ratings of thirteen federal government agencies. Rochester, NY: Harris Polls; February 7, 2007. <http://www.prnewswire.com/news/index_mail.shtml?ACCT=104&STORY=/www/story/02-06-2007/0004521666&EDATE=>

Mason H. Federal scorecard: Americans rate U.S. agencies. Government & Public Affairs 2003.

Syndemics

Prevention Network

Contrasting Strategies for Directing Social Change

Advocating Mobilizing Organizing

Definition• Pleading in another’s behalf

• Assembling or coordinating for a purpose

• Arranging systematically for harmonious functioning or united action

Form • A voice • A following • A working whole

Products • Special interests • Mass movements • Public work

In Practice

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

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

Syndemics

Prevention Network

2007

Extramural funding for methodology and technology (NIH Roadmap)

Symposia series on system science and health (NIH/OBSSR and CDC/SPN; ~6,000 participants)

Conference on complexity approaches to population health (Univ of Michigan; ~250 participants)

NIH monograph, “Greater Than the Sum”

• CDC monograph, “Hygeia’s Constellation”

• CDC to hire directors for preparedness modeling and public health systems research

• Concept mapping of public health policy resistance (NIH/OBSSR and CDC/SPN)

• Historical examples of health system transformation (CDC Public Health Practice Council)

• Methodology to support CDC’s focus on “health protection…health equity” (PriceWaterhouseCoopers)

2008

• Summer training institute for system science and health (NIH/OBSSR and CDC/SPN)

2009

• Extramural funding for “Health System Change” (NIH and CDC?)

What’s on the Horizon for System Science & Health?

Syndemics

Prevention Network

For Further Information

• CDC Syndemics Prevention Network http://www.cdc.gov/syndemics

• NIH/CDC Symposia on System Science and Healthhttp://obssr.od.nih.gov/Content/Lectures+and+Seminars/Systems_Symposia_Series/SEMINARS.htm

• Recommended Reading

– AJPH theme issue on systems thinking and modeling (March, 2006)http://www.ajph.org/content/vol96/issue3/

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

• Midgley G. Systemic intervention for public health. AJPH 2006;96(3):466-472.

• Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. AJPH 2006;96(3):452-458.

– Sterman JD. A skeptic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229. http://web.mit.edu/jsterman/www/Skeptic%27s_Guide.html

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

– Meadows DH, Robinson JM. The electronic oracle: computer models and social decisions. System Dynamics Review 2002;18(2):271-308.

Syndemics

Prevention Network

EXTRAS

Syndemics

Prevention Network

Left Unexamined…

• Singular “program” as the unit of inquiry (N=1 organizational depth)

• Dynamic aspects of program effectiveness (e.g., better-before-worse patterns of change)

• Democratic aspects of public health work (e.g., alignment among multiple actors, including those who are not health professionals—or professionals at all—and those who may be pursuing other goals)

• Evaluative aspects of planning and policy development

Milstein B, Wetterall S, CDC Evaluation Working Group. Framework for program evaluation in public health. MMWR Recommendations and Reports 1999;48(RR-11):1-40. Available at <http://www.cdc.gov/mmwr/PDF/RR/RR4811.pdf>.

Framework for Program Evaluation“Both a synthesis of existing evaluation practices

and a standard for further improvement.”

Syndemics

Prevention Network

Revisiting the Framework

Simulation Modeling Offers

• Support for multi-stakeholder dialogue

• A larger conception of the “program” context in its policy context

• An avenue for experimentation without comparison/control groups and visceral learning

• Ability to track interrelated indicators (both states and rates)

• An emphasis on pragmatism (learning through action)

• A focus on the evaluative aspects of planning and policy development

“Steps in the framework are starting points for tailoring an evaluation to a particular public health effort at a particular time.”

Milstein B, Wetterall S, CDC Evaluation Working Group. Framework for program evaluation in public health. MMWR Recommendations and Reports 1999;48(RR-11):1-40. Available at <http://www.cdc.gov/mmwr/PDF/RR/RR4811.pdf>.

Syndemics Prevention Network Syndemics, System Science, and the Prospect of Navigating Health Futures Bobby Milstein Syndemics Prevention Network Centers.

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