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Syndemics
Prevention Network
Navigating Health Futures in a Dynamic and Democratic World
Bobby Milstein
Syndemics Prevention NetworkCenters for Disease Control and Prevention
[email protected]://www.cdc.gov/syndemics
University of Auckland School of Population HealthNew Zealand Ministry of Health
Auckland: September 12-14, 2007Wellington: September 19-21, 2007
Syndemics
Prevention Network
Topics for Today
• Principles of a Syndemic Orientation
• A Navigational View of Public Health Work
• Dealing with Dynamic Complexity
– Policy resistance
– Boundary critique
– Crafting high-leverage interventions
– Causal mapping and simulation modeling
– Building power
• Illustrations
– North Karelia Project
– CDC Diabesity Modeling
– Industrial Areas Foundation
• Questions and Discussion Throughout
Syndemics
Prevention Network
• Common
• Diverse
• Interconnected
• Increasing
• Costly
• Debilitating
• Deadly
• Inequitably distributed
• Largely preventable
Chronic Conditions Here (and Everywhere) Are…
Defy quick fixes and require a sound system-wide strategy to protect health as well as other values
Syndemics
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.
How to Meet the Challenge?
How is it directed?
How are innovators approaching the challenge of assuring more healthful and
equitable conditions?
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
Epi·demic
• The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people
• Epidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic Diseases“
• Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.
Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htm
National Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/
Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873.
A representation of the cholera epidemic of the nineteenth century.Source: NIH
“The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.”
-- Gil Elliot
Syndemics
Prevention Network
Syn·demic
• The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena
• It acknowledges relationships and signals a commitment to studying population health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways
Confounding
Connecting*
Synergism
Syndemic
Events
System
Co-occurring
* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping
Syndemics
Prevention Network
Time Series Models
Describe trends
Multivariate Stat Models
Identify historical trend drivers and correlates
Patterns
Structure
Events
Increasing:
• Depth of causal theory
• Robustness for longer-term projection
• Value for developing policy insights
• Degrees of uncertainty
Increasing:
• Depth of causal theory
• Robustness for longer-term projection
• Value for developing policy insights
• Degrees of uncertaintyDynamic Simulation Models
Anticipate new trends, learn about policy consequences,
and set justifiable goals
Tools for Policy Planning & Evaluation
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
Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004.
Working DefinitionSyndemic Orientation
A way of thinking about public health work that
focuses on connections among health-related
problems, considers those connections when
developing health policies, and aligns with other
avenues of social change to assure the
conditions in which all people can be healthy
Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense
Incorporates 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.
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., ?)
• Single disease, single cause (e.g., ?)
• Single disease, multiple causes (e.g., ?)
• Single cause, multiple diseases (e.g., ?)
• Multiple causes, multiple diseases (but no feedback dynamics) (e.g., ?)
• Dynamic feedback among afflictions, living conditions, and public strength (e.g., ?)
1880
1950
1960
1980
2000
1840
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006.
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Syndemics
Prevention Network
Exposes the Dynamic and Democratic Dimensions of Public Health Work
PUBLIC HEALTH WORK
InnovativeHealth
Ventures
UNDERSTANDING CHANGESystems Science
• What causes population health problems?
• How are efforts to protect the public’s health organized?
• How and when do health systems change (or resist change)?
SETTING DIRECTIONPublic Health
What are health leaderstrying to accomplish?
GOVERNING MOVEMENTSocial Navigation
Directing Change
Charting Progress
• Who does the work?• By what means?• According to whose values?
• How are conditions changing?• In which directions?
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
Reconnecting with a Voyaging Tradition
-- Polynesian Voyaging Society
“Nainoa Thompson, who studied under Mau Pialug, became the first Hawaiian navigator in over 500 years to guide a canoe over this traditional route without instruments.”
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. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.
Where we want to go?
How do we prepare to get there?
Where do you want your children to live?
Where you do want to live?
Syndemics
Prevention Network
A Navigational View of Public Health Work
"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
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>.
Syndemics
Prevention Network
A Navigational View of Public Health Work
"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
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>.
Syndemics
Prevention Network
Foundations of Directed Change
Science ConscienceConsciousness
Scire, to know
Facts EffectsSelf
Knowledge MoralityPower
Syndemics
Prevention Network
Chronic Conditions are Classic Examples of Dynamically Complex Problems
• Differences between short- and long-term consequences of an action
• Time delays (e.g., developmental period, time to detect, time to respond)
• Accumulations (e.g., prevalences, resources, attitudes)
• Behavioral feedback (e.g., reactions by various actors)
• Nonlinear causal relationships (e.g., threshold effects, saturation effects)
• Differences or inconsistencies in goals/values among stakeholders
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458.
Syndemics
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
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
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>.
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
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 of service delivery, but not too far as to miss the internal pressures of vulnerability, capacity, and health status
• Potential to explain temporal patterns (e.g., better before worse)
• Structure determines behavior
• Potential to avoid scapegoating
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
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
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
Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995.
National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.
Navigational VenturesFinland’s North Karelia Project
Syndemics
Prevention Network
Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995
Focusing the Intervention Policy
Policy A: Focus on High Risk Individuals
Policy B: Focus on Risk Conditions for All
Syndemics
Prevention Network
Broad Intervention PolicyNorth Karelia Project
Disease Burden
Disease Burden
Individual Effort
Public Work
Adapted from Puska P. North Karelia International Visitors’ Programme, 2003.
Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at <http://www.publicwork.org/1_2_philosophy.html>.
Syndemics
Prevention Network
Directing ChangeNorth Karelia Project
Selected Action Strategies
• Medical services, if necessary
• Newspaper coverage: articles, editorials, letters
• TV time: highly rated 30-45 minute shows (no PSAs)
• Housewives’ organization: cooking and dietary choices
• Opinion leaders: role models, support groups, public action
• Tax shifting: tobacco, butter, milk
• Economic Renewal– Decline of dairy – Rise of berry – Rise of vegetable oil and rapeseed oil– Rise of healthier breads, cheeses, sausages, etc
Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995.
Syndemics
Prevention Network
Transforming All Dimensionsof the System
Health
LivingConditions
Power toAct
Efforts to Fight Afflictions
Efforts to Improve Adverse Living Conditions
Efforts to Build Power
Syndemics
Prevention Network
Efforts to Fight Afflictions (design/deliver)
• Screening
• Education
• Risk reduction counseling
• Medical/pharmaceutical treatment
• Disease self-management
Directing ChangeNorth Karelia Project
Syndemics
Prevention Network
Efforts to Improve Adverse Living Conditions (develop/promote)
• Tobacco legislation
• Food-labeling requirements
• Margarines and oils
• Low-fat milk
• Low-fat, low-salt, high-fiber bread
• Vegetable-containing sausage (with mushrooms)
• Berry farming and consumption
• Community competitions, morale, and social norms
• State welfare system (at the national, regional, sub-regional, and local levels)
Directing ChangeNorth Karelia Project
Syndemics
Prevention Network
Health Professionals
• Physicians
• Health Educators
• Psychologists
• Epidemiologists
• Sociologists
• Hospital administrators
• Pharmaceutical manufacturers
• Nurses
• Rehabilitation therapists
Other Citizens
• Bakers
• Farmers
• Grocers
• Food scientists, manufacturers
• Restaurant owners
• Housewives
• Entertainers
• Entrepreneurs
• Journalists, media professionals
• Teachers
• School administrators
• Elected representatives
Building PowerNorth Karelia Project
Syndemics
Prevention Network
Charting ProgressNorth Karelia Project
Vartiainen E, Puska P, Pekkanen J, Toumilehto J, Jousilahti P. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. British Medical Journal 1994;309(6946):23-27.
Syndemics
Prevention Network
Mortality changes in North Karelia in 1970-1995 (per 100 000, 35-64 years, men, age adjusted)
0
200
400
600
800
1000
1200
1400
1600
All Causes All CVD CHD All Cancers Lung CancerCause of Death
Ra
te p
er
10
0,0
00
1979
1995
-49%
-68%-73%
-44%-71%
Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995.
National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Accessed May 30, 2004 at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.
Charting ProgressNorth Karelia Project
Syndemics
Prevention Network
Framing the Challenge of Chronic Illness
PERSONPeople living with
affliction
PLACEAreas with a
recurring problem of affliction
TIMEPeople
vulnerable to affliction
HealthStates &
Rates
Syndemics
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
Syndemics
Prevention Network
Balancing Two Major Areas of Emphasis
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
ComplicationsAfflicted with
ComplicationsBecomingvulnerable
Becoming saferand healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
Demand forresponse
GeneralProtection
TargetedProtection
PrimaryPrevention
SecondaryPrevention
TertiaryPrevention
Public Work
World of Providing…
• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…
Medical and Public Health Policy
MANAGEMENT OF DISEASES AND RISKS
World of Transforming…
• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.
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. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Choice and Non-Choice
Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93.
“Choices are always made from among
alternatives presented by the social
environment, or by circumstances that were
themselves not chosen…When we recognize the
elements of non-choice in choice, we can escape
the contradiction between social causation and
individual responsibility and understand the
interactiveness of the two.”
Syndemics
Prevention Network
Understanding Health as Public Work
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
Becoming saferand healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
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
Evaluating Dynamic, Democratic Policies
How can we learn about the consequences of alternative policies in a system of this kind?
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
Becoming saferand healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
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
System Dynamics Was Developed to Address Problems Marked By Dynamic Complexity
Good at Capturing
• Differences between short- and long-term consequences of an action
• Time delays (e.g., incubation period, time to detect, time to respond)
• Accumulations (e.g., prevalences, resources, attitudes)
• Behavioral feedback (reactions by various actors)
• Nonlinear causal relationships (e.g., threshold effects, saturation effects)
• Differences or inconsistencies in goals/values among stakeholders
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458.
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
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.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Syndemics
Prevention Network
A Model Is…
An inexact representation of the real thing
They help us understand, explain, anticipate, and make decisions
“All models are wrong, some are useful.”
-- George Box
“All models are wrong, some are useful.”
-- George Box
Syndemics
Prevention Network
Selected CDC Projects Featuring System Dynamics Modeling
• Syndemics Mutually reinforcing afflictions
• Diabetes In an era of rising obesity
• ObesityLifecourse consequences of changes in caloric balance
• Infant HealthFetal and infant morbidity/mortality
• PolioReintroductions after eradication
• Heart Disease and StrokePreventing and managing multiple risks, in context
Milstein B, Homer J. Background on system dynamics simulation modeling, with a summary of major public health studies. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; February 1, 2005. <http://www2.cdc.gov/syndemics/pdfs/SD_for_PH.pdf>.
• Grantmaking ScenariosTiming and sequence of outside assistance
• Upstream-Downstream EffortBalancing disease treatment with prevention/protection
• Healthcare ReformRelationships among cost, quality, equity, and health status
Syndemics
Prevention Network
Simulations for Learning in Dynamic Systems
Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Multi-stakeholder Dialogue
Dynamic Hypothesis (Causal Structure)
X Y
Plausible Futures (Policy Experiments)
Obese fraction of Adults (Ages 20-74)
0%
10%
20%
30%
40%
50%
1970 1980 1990 2000 2010 2020 2030 2040 2050
Fra
ctio
n o
f p
op
n 2
0-74
Syndemics
Prevention Network
Model Uses and Audiences
• Set Better Goals (Planners & Evaluators)
– Identify what is likely and what is plausible– Estimate intervention impact time profiles– Evaluate resource needs for meeting goals
• Support Better Action (Policymakers)
– Explore ways of combining policies for better results– Evaluate cost-effectiveness over extended time periods– Increase policymakers’ motivation to act differently
• Develop Better Theory and Estimates (Researchers)
– Integrate and reconcile diverse data sources– Identify causal mechanisms driving system behavior– Improve estimates of hard-to-measure or “hidden” variables
Syndemics
Prevention Network
CDC Diabetes System Modeling ProjectDiscovering Stock-Flow Dynamics Through Action Labs
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.
Syndemics
Prevention Network
CDC Diabetes System Modeling Project
• Diabetes programs face tough challenges and questions
– With rapid growth in prevalence, is improved control good enough?
– Studies show primary prevention is possible, but how much impact in practice and at what cost?
– How best to balance interventions?
• Model developed with program planners, diabetes researchers, and epidemiologists
• Model-based “learning lab” workshops for planners—federal, state, and local
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.
Done in conjunction with Sustainability Institute and the Center for Public Health Practice at Emory University
Syndemics
Prevention Network
Health Care & Public Health Agency Capacity
• Provider supply• Provider understanding, competence• Provider location• System integration• Cost of care• Insurance coverage
Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
Progression ofDx S1 to S2
S2 deaths
High RiskNot
Prediabetic
UndiagnosedStage 1
Diabetics
Diagnosis ofS1 diabetes
Progression ofUndx S1 to S2
GeneralPopulation
BecomeHigh Risk
Rehab ofHigh Risk
UndiagnosedPrediabetic
DiagnosedPrediabetic
Diabetes onsetfrom Undx PreD
Diabetes onsetfrom Dx PreD
Diagnosis ofPrediabetes
Prediabetesonset
Rehab ofUndx PreD
Rehab ofDx PreD
We Convened a Model-Scoping Group of 45 CDC professionals and epidemiologists in December 2003 to Explore the Full Range of Forces Driving Diabetes Behavior over Time
Personal Capacity
• Understanding• Motivation• Social support• Literacy• Physio-cognitive function• Life stages
Metabolic Stressors
• Nutrition• Physical activity• Stress
• Baseline Flows
Health Care Utilization
• Ability to use care (match of patients and providers, language, culture)• Openness to/fear of screening• Self-management, monitoring
• Percent of patients screened• Percent of people with diabetes under control
Civic Participation
• Social cohesion• Responsibility for others
Forces Outside the Community
• Macroeconomy, employment• Food supply• Advertising, media• National health care• Racism• Transportation policies• Voluntary health orgs• Professional assns• University programs• National coalitions
Local Living Conditions
• Availability of good/bad food• Availability of phys activity• Comm norms, culture (e.g., responses to racism, acculturation)• Safety• Income• Transportation• Housing• Education
Syndemics
Prevention Network
Inflow
Volume
Outflow
Developing
Burden ofDiabetes
Total Prevalence(people with diabetes)
Unhealthy Days(per person with
diabetes)
Costs(per person with diabetes)
People withDiagnosedDiabetes
Diagnosis Deaths
abPeople withPrediabetes
Developing
DiabetesOnset
c
d
People withNormal
Blood SugarLevels
PrediabetesOnset
Recovering fromPrediabetes
e
DiabetesManagement
DiabetesDetection
Obesity in theGeneral
Population
PrediabetesDetection &
Management
People withUndiagnosed
Diabetes
Deaths
Overview of Diabetes Stock-and-Flow Model
Syndemics
Prevention Network
Overview of Diabetes Stock-and-Flow Model
Inflow
Volume
Outflow
Developing
Burden ofDiabetes
Total Prevalence(people with diabetes)
Unhealthy Days(per person with
diabetes)
Costs(per person with diabetes)
People withDiagnosedDiabetes
Diagnosis Deaths
abPeople withPrediabetes
Developing
DiabetesOnset
c
d
People withNormal
Blood SugarLevels
PreDiabetesOnset
Recovering fromPreDiabetes
e
DiabetesManagement
DiabetesDetection
Obesity in theGeneral
Population
PrediabetesDetection &
Management
People withUndiagnosed
Diabetes
Deaths
Standard boundary
This larger view takes us beyond standard epidemiological models and most intervention programs
Syndemics
Prevention Network
Using Available Data to Ground the Model
Information Sources Data
U.S. Census
• Population growth and death rates• Fractions elderly, black, hispanic• Health insurance coverage
National Health Interview Survey• Diabetes prevalence• Diabetes detection
National Health and Nutrition Examination Survey• Prediabetes prevalence
• Obesity prevalence
Behavioral Risk Factor Surveillance System
• Eye exam and foot exam• Taking diabetes medications• Unhealthy days (HRQOL)
Professional Literature• Effects of risk factors and mgmt on onset, complications, and costs• Direct and indirect costs of diabetes
Syndemics
Prevention Network
One way we establish the model’s value is by looking at its ability to reproduce historical data
(2 variables out of 10 such comparisons)
Diagnosed diabetes per thousand total popn60
45
30
15
0
1980 1984 1988 1992 1996 2000 2004
Model
NHIS
Model
Diagnosed fraction of diabetes popn1
0.8
0.6
0.4
1980 1984 1988 1992 1996 2000 2004
NHANES IIINH
’99 -’00NH II
Homer J. Reference guide for the CDC Diabetes System Model. Atlanta, GA: Division of Diabetes Translation, Centers for Disease Control and Prevention; August, 2006. <<http://sustainer.org/pubs/diabetessystemreference.pdf>.
Syndemics
Prevention Network
Healthy People 2010 Diabetes Objectives:What Can We Accomplish?
-11%7.88.8 per 1,000
Reduce Diabetes–related Deaths Among Diagnosed
(5-6)
-38%2540 per 1,000
Reduce Prevalence of Diagnosed Diabetes
(5-3)
-29%2.53.5per 1,000
Reduce New Cases of Diabetes (5-2)
Increase Diabetes Diagnosis (5-4)
+18%80%68%
Percent Change
HP 2010 Target
Baseline
U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm
Syndemics
Prevention Network
A History of Missed Goals
Simulations have helped diabetes planners set more realistic goals.
Simulations have helped diabetes planners set more realistic goals.
Milstein B, Jones A, Homer J, Murphy D, Essien J, Seville D. Charting plausible futures for diabetes prevalence: A role for system dynamics simulation modeling. Preventing Chronic Disease July 2007. <http://www.cdc.gov/pcd/issues/2007/jul/06_0070>
20
30
40
50
60
1980 1985 1990 1995 2000 2005 2010
Time (Years)
Peo
ple
with
Dia
gnos
ed D
iabe
tes
per
1,00
0 P
opn
HP 2000 prevalence goal HP 2010
prevalence goal
Status quo(simulated)
+33%
-11%
-38%
Diagnosed Diabetes Prevalence per Thousand AdultsMeet HP2010 detection goal
Meet HP2010 onset goal
Surveillance data (NHIS)
+25%
Syndemics
Prevention Network
Connecting the ObjectivesPopulation Flows and Dynamic Accounting 101
It is impossible for any policy to reduce prevalence
38% by 2010!
People withUndiagnosed
Diabetes
People withDiagnosedDiabetes Dying from Diabetes
Complications
DiagnosedOnset
InitialOnset
PeoplewithoutDiabetes
As would stepped-up detection effort
Reduced death wouldadd further to prevalence
With a diagnosed onset flow of
1.1 mill/yr
And a death flow of 0.5 mill/yr
(4%/yr rate)
The targeted 29% reduction in diagnosed onset can only
slow the growth in prevalence
Milstein B, Jones A, Homer J, Murphy D, Essien J, Seville D. Charting plausible futures for diabetes prevalence: A role for system dynamics simulation modeling. Preventing Chronic Disease July 2007. <http://www.cdc.gov/pcd/issues/2007/jul/06_0070>
Syndemics
Prevention Network
Mon
thly
Unh
ealth
y D
ays
from
D
iabe
tes
per
Tho
usan
d
Policy Testing…and Reason for Hope
With a combination of improved control and aggressive primary prevention, growth in the burden of diabetes could
be limited for the next 10 years and for decades beyond.
With a combination of improved control and aggressive primary prevention, growth in the burden of diabetes could
be limited for the next 10 years and for decades beyond.
U.S. Morbidity from Diabetes Simulated 1980-2050
600
500
400
300
200
1980 1990 2000 2010 2020 2030 2040 2050
Combination
Primary prevention
Base
Control
Syndemics
Prevention Network
The Modeling Process is Having an Impact
• Budget for primary prevention was doubled– from meager to modest
• HP2010 prevalence goal has been modified– from a large reduction to no change (but still not an increase)
• Research, program, and policy staff are working more closely– Many new leaders emerging, but truly cross-functional
teams are still forming
• State health departments and their partners are now engaged– initial efforts in 13 states
Syndemics
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
People inPlaces
BoundaryCritique
Governing Dynamics
Ca
us
al
Ma
pp
ing
Plausible Futures
DynamicModeling
Navigational Freedoms
De
mo
cra
tic
Pu
bli
c W
ork
Syndemics
Prevention Network
“Academics and pundits love to throw around the term ‘social capital’
and debate its nuances, but most of them couldn’t
organize a block party.”
-- Ed Chambers
Power Has to be Organized
Chambers ET, Cowan MA. Roots for radicals. New York: Continuum, 2003., p. 65.
Syndemics
Prevention Network
Growth of Citizen Leaders
“Almost everyone knows about the
explosion of the dot-coms…but millions
have still not heard the big story: the
worldwide explosion of dot-orgs.
More people today have the freedom,
time, wealth, health, exposure, social
mobility, and confidence to address
social problems in bold new ways.”
-- David Bornstein
Bornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004.
Number of Public Service GroupsRegistered with IRS
0
500,000
1,000,000
1989 1998
Nu
mb
er
Re
gis
tere
d
60%
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
Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004. <http://www.industrialareasfoundation.org/>.
Living wage
Nehemiah Homes
Alliance Schools
Quest job training
Blight removal
Environmental cleanup
After school programs
Smaller high schools
Organizing PowerIAF Issue Campaigns
Syndemics
Prevention Network
Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004. <http://www.industrialareasfoundation.org/>.
• Broad-based, multi-issue orgs, built to win and built to last
• Power precedes programs
• Never do for others what they can do for themselves
• The world as it is vs. the world as it should be
• Act to get a specific reaction
• Public accountability begins with self-accountability
• No permanent allies, no permanent enemies
• Organize, disorganize, reorganize
Organizing PowerIAF Principles
Syndemics
Prevention Network
Organizing PowerIAF Organizing Activities
• Have relational meetings
• Find and train leaders
• Recruit institutions and allies
• Pay dues
• Do research (problems, power, interests)
• Act on winnable issues
• Evaluate every action
• Organize, disorganize, reorganize
Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004. <http://www.industrialareasfoundation.org/>.
Syndemics
Prevention Network
Revisiting our Hypothesis of Health System Dynamics
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
Afflicted withComplications
Developingcomplications
Dying fromComplications
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Health System Dynamics Incorporating Public vs. Professional Concern
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Downstreamwork
Professionalconcern
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Health System Dynamics Incorporating Public vs. Professional Concern
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onprogression
-
Effect oncomplications
-
TertiaryPrevention
SecondaryPrevention
Downstreamwork
Professionalconcern
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Health System Dynamics Incorporating Public vs. Professional Concern
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onprogression
-
Effect oncomplications
-
TertiaryPrevention
SecondaryPrevention
Vulnerable andAfflicted Population
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
Publicwork
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Health System Dynamics Incorporating Public vs. Professional Concern
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Population
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
-
Publicwork
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Health System Dynamics Incorporating Public vs. Professional Concern
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Population
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
SocialDisparity
-
Citizen Involvementand Organizing
SocialDivision
-
Publicwork
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
Health System Dynamics Incorporating Public vs. Professional Concern
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onincidence
-
Effect onprogression
-
Effect oncomplications
-
Effect on livingconditions
Effect onvulnerabilityreduction
GeneralProtection
TargetedProtection
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
Vulnerable andAfflicted Population
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
SocialDisparity
-
Citizen Involvementand Organizing
SocialDivision
-
Publicwork
Institutional/organizationalemphasis on disease rather
than vulnerability
-
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics
Syndemics
Prevention Network
SummaryWhy is it So Hard to Work Across the Whole System?
Initial Observations
• Upstream work requires more public concern, which is less a reaction to the prevalence of disease as to the spread of vulnerability and affliction that over many years threaten everybody (think of economic decline, inadequate education, unsafe housing, sprawl, racism, environmental decay, etc.)
• Long before upstream threats become widely apparent, money and other resources have focused downstream (where professional expertise and the weight of scientific evidence lie)
• Because of their role as providers of downstream services, health professionals do not respond to vulnerability and social inequity FOR ITS OWN SAKE, in the WAY that ordinary citizens often do
• Upstream health action involves broad-based organizing; it is political—but non-partisan—and cannot be done by professionals alone.
Syndemics
Prevention Network
“I can see how connected the
Māori are to their ancestry. And
because they are connected to
their past, I believe that it's much
easier for them to see the kind of
future they want to voyage to.”
-- Nainoa Thompson
Thompson N. The voyage of rediscovery: 1985-1987. Polynesian Voyaging Society, 2005. Available at <http://www.pvs-hawaii.com/newsletters/nl_rediscovery.htm>.
Voyage of RediscoveryHawaii – Aotearoa, 1985-1987