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Syndemic Thinking in the CDC Futures Initiative
Syndemic Thinking in the CDC Futures Initiative
Bobby Milstein NCCDPHP Strategy Planning Process
December 22, 2003
Bobby Milstein NCCDPHP Strategy Planning Process
December 22, 2003
CDC Futures Initiative Directions and Open Questions
CDC Futures Initiative Directions and Open Questions
What are the major challenges that stand in the way of greater effectiveness
For CDC as an organization?
For public health work as a societal endeavor?
Is the basic problem organizational disarray, which requires rearranging, or disorientation, which demands new approaches to thinking, problem framing, decision making, and organizing itself?
What are the major challenges that stand in the way of greater effectiveness
For CDC as an organization?
For public health work as a societal endeavor?
Is the basic problem organizational disarray, which requires rearranging, or disorientation, which demands new approaches to thinking, problem framing, decision making, and organizing itself?
What Does it Mean to Approach Public Health Work from a Syndemic Orientation?
What Does it Mean to Approach Public Health Work from a Syndemic Orientation?
Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. Accessed December 15, 2002 at <http://www.cdc.gov/syndemics>.
http://www.cdc.gov/syndemics
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Planned as a three-year study of innovations in health planning and evaluation
Member network includes
158 individuals
123 organizations
11 countries
Planned as a three-year study of innovations in health planning and evaluation
Member network includes
158 individuals
123 organizations
11 countries
Phases of the Syndemics ProjectPhases of the Syndemics Project
Phase 1: explore trends, dilemmas, and innovations; develop working definitions; identify core concepts and methods
Phase 2: articulate the foundations of a syndemic orientation; work with others to use this perspective in transforming public health work at the CDC and beyond
Phase 1: explore trends, dilemmas, and innovations; develop working definitions; identify core concepts and methods
Phase 2: articulate the foundations of a syndemic orientation; work with others to use this perspective in transforming public health work at the CDC and beyond
CDC Futures Initiative Observations on Our Present Position
CDC Futures Initiative Observations on Our Present Position
Silos (organizational fragmentation)
Arrogance
Inefficient internal processes (molasses)
Focus on processes, not impact
Difficulty differentiating CDC work from other agencies
Persistent gap between science and practice (intrusion of politics?)
Disconnect between CDC work and public perception (niches of opportunity)
Window of opportunity for CDC leadership (on health system reform, informatics, chronic illness, and prevention broadly)
Silos (organizational fragmentation)
Arrogance
Inefficient internal processes (molasses)
Focus on processes, not impact
Difficulty differentiating CDC work from other agencies
Persistent gap between science and practice (intrusion of politics?)
Disconnect between CDC work and public perception (niches of opportunity)
Window of opportunity for CDC leadership (on health system reform, informatics, chronic illness, and prevention broadly)
CDC Futures Initiative Possible Stakes in the Ground
CDC Futures Initiative Possible Stakes in the Ground
View public as the primary customer
Lead emphasis on prevention (and protection?) throughout the
Health care delivery system (certainly)
Public health system (certainly)
Society (?)
Loosen fragmentation, but don’t lose specialization
Stimulate organizational evolution, not revolution (i.e., do not disrupt or dismantle existing infrastructure but make it grow in new, more balanced directions)
Use, but don’t become captured by the language of customer and products
View public as the primary customer
Lead emphasis on prevention (and protection?) throughout the
Health care delivery system (certainly)
Public health system (certainly)
Society (?)
Loosen fragmentation, but don’t lose specialization
Stimulate organizational evolution, not revolution (i.e., do not disrupt or dismantle existing infrastructure but make it grow in new, more balanced directions)
Use, but don’t become captured by the language of customer and products
CDC’s Shifting OrientationsCDC’s Shifting Orientations
MedicalOrientation
Customer ServiceOrientation
TransformationalOrientation
What is Transforming? • People’s health status• Conditions for health (threats)• Health response systems• CDC culture• Scientific methods• The way we think about and organize public health work
Elements of a syndemic orientation may help as we navigate these transitions
Elements of a syndemic orientation may help as we navigate these transitions
1946 1990 2000
Why Do We Do Public Health Work?Why Do We Do Public Health Work?
CDC Vision & Mission
Healthy people, in a healthy world, through prevention
To promote health and quality of life by preventing and controlling
disease, injury, and disability
CDC Vision & Mission
Healthy people, in a healthy world, through prevention
To promote health and quality of life by preventing and controlling
disease, injury, and disability
Institute of Medicine
The purpose of public health is to fulfill society’s interest in
assuring the conditions in which people can be healthy
Institute of Medicine
The purpose of public health is to fulfill society’s interest in
assuring the conditions in which people can be healthy
How we reconcile these two frames of reference will shape the possibilities for leading health system change
How we reconcile these two frames of reference will shape the possibilities for leading health system change
Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.
"In problem solving we seek to make something we do not like
go away. In creating, we seek to make what we truly care
about exist… We can get so caught up in reacting to problems
that it is easy to forget what we actually want. Organizations
must do both–resolve day-to-day problems and generate new
results. But if your primary role is to fix problems, individually
or collectively, rather than create something new and
meaningful, it's hard to maintain a sense of purpose, and..it's
difficult to harness the energy, passion, commitment, and
perseverance needed to thrive in challenging times."
"In problem solving we seek to make something we do not like
go away. In creating, we seek to make what we truly care
about exist… We can get so caught up in reacting to problems
that it is easy to forget what we actually want. Organizations
must do both–resolve day-to-day problems and generate new
results. But if your primary role is to fix problems, individually
or collectively, rather than create something new and
meaningful, it's hard to maintain a sense of purpose, and..it's
difficult to harness the energy, passion, commitment, and
perseverance needed to thrive in challenging times."
Solving Problems vs. Creating ValueSolving Problems vs. Creating Value
-- Peter Senge-- Peter Senge
Public Health Goals Are Expanding…and Accumulating
Public Health Goals Are Expanding…and Accumulating
Prevent disease and injury (~1850 -- present)
Promote health and development (1974 -- present)
Assure the conditions in which people can be healthy (1988 -- present)
Prevent disease and injury (~1850 -- present)
Promote health and development (1974 -- present)
Assure the conditions in which people can be healthy (1988 -- present)
“The perfection of means and confusion of goals characterizes our age.”
-- Albert Einstein
“The perfection of means and confusion of goals characterizes our age.”
-- Albert Einstein
What does it mean to organize science and society around the goal of assuring healthful conditions?
What does it mean to organize science and society around the goal of assuring healthful conditions?
Plan for TodayPlan for Today
Core ideas leading to a syndemic orientation
Health system dynamics
Health Systems Workgroup report (Figure 1)
Working toward a more balanced health system
Living conditions and the role of individual behavior
Importance of simulation modeling
Progress in systems modeling (if we have time)
Steps for putting maps in motion
Examples from three on-going modeling projects
Core ideas leading to a syndemic orientation
Health system dynamics
Health Systems Workgroup report (Figure 1)
Working toward a more balanced health system
Living conditions and the role of individual behavior
Importance of simulation modeling
Progress in systems modeling (if we have time)
Steps for putting maps in motion
Examples from three on-going modeling projects
Seeing SyndemicsSeeing Syndemics“You think you understand two because you understand one and
one. But you must also understand ‘and’.”
-- Sufi Saying
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)
Ideas About InteractionIdeas About Interaction
Confounding
Connecting*
Synergism
Syndemic
* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping
Events
Systems
Co-occurring
Placing Health in a Wider Set of Relationships
Placing Health in a Wider Set of Relationships
Health
LivingConditions
Capacity toAct
A syndemic orientation is one of a few approaches that includes within it our power to respond
A syndemic orientation is one of a few approaches that includes within it our power to respond
Vision Element Main Task
Healthy People Improve health
Healthy World Enhance living conditions
Through Prevention Strengthen capacity
(public work for health)
CDC’s Vision for the 21st Century
Healthy People, in a Healthy World--Through Prevention
CDC’s Vision for the 21st Century
Healthy People, in a Healthy World--Through Prevention
Working Across Multiple ScalesWorking Across Multiple Scales
Goals People Places
Part Prevent disease
and injury People with affliction Neighborhoods
Whole Promote health and
development
Sub-groups with greater burden of affliction
Regions
Greater Whole
Assure conditions in which people can be healthy
Society with a recurring problem of inequitable burden
Planet
Innovations in Public Health WorkInnovations in Public Health WorkSteps in Public Health Problem Solving Trends and Emerging Priorities
Define the problem
Eliminate health disparities
Avoid activity limitation
Promote life satisfaction
Increase healthy days
Determine the cause
Social determinants of health
Income inequality
Eroding social capital
Unhealthy built environment
Adverse childhood experiences
Develop and test interventions
Comprehensive community initiatives
Ecological perspectives
Inter-sector collaboration
Health impact assessments
Implement programs and policies
Policy interventions
Community and systems change
Adaptation to local context
And scores more….And scores more….
Public health work is becoming more…
Inter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control
Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability
Questioning (evaluative, reflexive, practical)Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends
Public health work is becoming more…
Inter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control
Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability
Questioning (evaluative, reflexive, practical)Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends
Innovations Point to the Emergence of a Syndemic Orientation
Innovations Point to the Emergence of a Syndemic Orientation
Many other orientations rely on disconnected, singular, and unthinking approaches where means and ends have very different qualities (e.g., security by means of war)
Many other orientations rely on disconnected, singular, and unthinking approaches where means and ends have very different qualities (e.g., security by means of war)
A Complementary Science of Relationships
A Complementary Science of Relationships
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Protects the Public’s HealthDynamic interaction among multiple problems, problem solvers, and responses
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Protects the Public’s HealthDynamic interaction among multiple problems, problem solvers, and responses
Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation
System Dynamics
SocialNavigation
POLICYDEVELOPMENT
ASSESSMENT
ASSURANCE
NetworkAnalysis
CategoricalOrientationSyndemic
Orientation
Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation
System Dynamics
SocialNavigation
POLICYDEVELOPMENT
ASSESSMENT
ASSURANCE
NetworkAnalysis
CategoricalOrientationSyndemic
Orientation
Techniques • Causal diagramming• Storytelling, scenario-based planning• Game-based learning• Simulation experiments• Health impact assessment
Techniques • Leadership/institutional development• Power and interest mapping• Broad-based, multi-issue organizing• Action planning• Public work• Flow charting (logic mapping)• Journey mapping• Navigational statistics
Techniques • Problem naming• Network analysis• Time-trend analysis• Summary measures
The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people
Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“
Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people
Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“
Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.
“Public death was first recognized as a matter of civilized
concern in the nineteenth century, when some public health
workers decided that untimely death was a question
between men and society, not between men and God. Infant
mortality and endemic disease became matters of social
responsibility. Since then, and for that reason, millions of
lives have been saved….The pioneers of public health did
not change nature, or men, but adjusted the active
relationship of men to certain aspects of nature so that the
relationship became one of watchful and healthy respect.
“Public death was first recognized as a matter of civilized
concern in the nineteenth century, when some public health
workers decided that untimely death was a question
between men and society, not between men and God. Infant
mortality and endemic disease became matters of social
responsibility. Since then, and for that reason, millions of
lives have been saved….The pioneers of public health did
not change nature, or men, but adjusted the active
relationship of men to certain aspects of nature so that the
relationship became one of watchful and healthy respect.
Public Health Began as Public WorkPublic Health Began as Public Work
-- Gil Elliot-- Gil Elliot
Changing (and Accumulating) Ideas in Causal Theory
What accounts for poor community health?
Changing (and Accumulating) Ideas in Causal Theory
What accounts for poor community health?
God’s will
Humors, miasma, ether
Poor living conditions, immorality (sanitation)
Single disease, single cause (germ theory)
Single disease, multiple causes (heart disease)
Single cause, multiple diseases (tobacco)
Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)
Dynamic feedback among afflictions, living conditions, and response capacity (syndemic)
God’s will
Humors, miasma, ether
Poor living conditions, immorality (sanitation)
Single disease, single cause (germ theory)
Single disease, multiple causes (heart disease)
Single cause, multiple diseases (tobacco)
Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)
Dynamic feedback among afflictions, living conditions, and response capacity (syndemic)
1880
1950
1960
1980
2000
1840
Focused Efforts to Prevent and Control Diseases Have Led to Major Achievements
Focused Efforts to Prevent and Control Diseases Have Led to Major Achievements
600
500
400
200
100
501950 1960 1970 1980 1990 1995
Rate if trend continued
Peak Rate
Actual Rate
Age-a
dju
sted D
eath
Rate
per
10
0,0
00
Popula
tion
1955 1965 1975 1985
300
700
Year
Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998
Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.
SpecializationA Proven Problem Solving Approach
SpecializationA Proven Problem Solving Approach
Identify disease
Determine causes
Develop and test interventions
Implement programs and policies
Identify disease
Determine causes
Develop and test interventions
Implement programs and policies
Repeat steps 1-4, as necessary!Repeat steps 1-4, as necessary!
But “Solutions” Can Also Create New Problems
But “Solutions” Can Also Create New Problems
Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904.
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
Side Effects of SpecializationSide Effects of SpecializationConfusion, inefficiency, organizational disarray
Competition for shared resources
Attention to “local” causes, near in time and space
Neglected feedback (+ and -)
Confounded evaluations
Coercive power dynamics
Priority on a single value, implicitly or explicitly devaluing others
Limited mandate to address context (living conditions) or infrastructure (public strength)
Disappointing track record, especially with regard to inequalities
Confusion, inefficiency, organizational disarray
Competition for shared resources
Attention to “local” causes, near in time and space
Neglected feedback (+ and -)
Confounded evaluations
Coercive power dynamics
Priority on a single value, implicitly or explicitly devaluing others
Limited mandate to address context (living conditions) or infrastructure (public strength)
Disappointing track record, especially with regard to inequalities
A
C
BD
E
A B C D EIssue Organizations
Neighborhood
Diseases of DisarrayDiseases of Disarray
Hardening of the categories
Tension headache between treatment and prevention
Hypocommitment to training
Cultural incompetence
Political phobia
Input obsession
Hardening of the categories
Tension headache between treatment and prevention
Hypocommitment to training
Cultural incompetence
Political phobia
Input obsession
Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.
Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.
Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.
Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.
Source: Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2003. Accessed March 21 at <http://apps.nccd.cdc.gov/HRQOL/>.
The picture looks different if we think about people’s overall state of health or affliction
The picture looks different if we think about people’s overall state of health or affliction
14% increase
Misleading Framing AssumptionsMisleading Framing AssumptionsStepwise progress will lead to system wide improvement
Focus on the events
Everything that happens must have a cause
That cause must be close in time and space
Instantaneous impacts
Causality runs one-way
Independence
Impacts are linear and constant
Stepwise progress will lead to system wide improvement
Focus on the events
Everything that happens must have a cause
That cause must be close in time and space
Instantaneous impacts
Causality runs one-way
Independence
Impacts are linear and constant
Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.
These assumptions overlook non-local forces of change, such as feedback and delay
These assumptions overlook non-local forces of change, such as feedback and delay
Basic Problem Solving OrientationsBasic Problem Solving Orientations
Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Event Oriented View
Problem Results
Goals
Situation
Decision
SideEffects
Feedback View
Goals
Environment
Decisions
Goals ofOthers
Actions ofOthers
“When we attribute behavior to
people rather than system structure
the focus of management becomes
scapegoating and blame rather than
the design of organizations in which
ordinary people can achieve
extraordinary results.”
“When we attribute behavior to
people rather than system structure
the focus of management becomes
scapegoating and blame rather than
the design of organizations in which
ordinary people can achieve
extraordinary results.”
-- John Sterman-- John Sterman
Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.
“The tendency to blame other people instead of the system is so strong
that psychologists call it the fundamental attribution error.”
“The tendency to blame other people instead of the system is so strong
that psychologists call it the fundamental attribution error.”
Is there some way to get a larger,
more dynamic overview of the
whole health system without
loosing sight of unique disease
processes?
Is there some way to get a larger,
more dynamic overview of the
whole health system without
loosing sight of unique disease
processes?
White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.
Good Quality of Life Until Death
Social and Environmental Conditions Favorable to Health
Behavioral Patterns that Promote Health
Low Population Risk
Few Events/ Only Rare Deaths
Full Functional Capacity/Low Risk of Recurrence
A Vision of the Future
Policy and Environmental Change
Behavior Change
Risk Factor Detection and Control Emergency
Care/Acute CaseManagement
Rehabilitation/ Long-term Case Management
InterventionApproaches
End-of-Life Care
Target Population - USTotal Population
281 millionIncreased Risk
tens of millionsper factor
Acute Events hundreds of
thousands per event
Chronic Afflictions hundreds of thousands
per condition
A Comprehensive Public Health Framework For Chronic Disease Prevention and Health Promotion
A Comprehensive Public Health Framework For Chronic Disease Prevention and Health Promotion
Fatal Complications
Unfavorable Social and Environmental Conditions
Adverse Behavioral Patterns
Major Risk Factors
First Event/ Diagnosis
Disability/Risk of Recurrent Episodes
The Present Reality
Goal 1 Goal 3 Goal 4 Goal 2
Increase Quality and Years of Healthy Life
Eliminate Disparities
Intervention Goals (based on Healthy People 2010, Heart Disease/Stroke)
HP 2O1O
Patterns
Events
Progression of Systems Thinking & Modeling
Progression of Systems Thinking & Modeling
Adapted from: Successful Systems, Inc.
IssueIdentification
Variable & Behavior Analysis
Time
IssueIdentification
Variable & Behavior Analysis
Causal Loop Mapping
Understanding Strategy &Policy Implications
Implementing Action Plan
StructureCausal Loop
MappingSimulationModeling
Time Series ModelsDescribe trends
Multivariate Stat Models
Identify historical trend drivers and correlates
Patterns
Structure
Events
Increasing:
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights
Increasing:
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights
Dynamic Models
Anticipate future trends, and find policies that maximize chances
of a desirable path
Tools for Policy DevelopmentTools for Policy Development
Developed by Jack Homer, Homer ConsultingDeveloped by Jack Homer, Homer Consulting
Different Modeling Approaches For Different Purposes
Different Modeling Approaches For Different Purposes
Logic Models
(flowcharts, maps or diagrams)
System Dynamics
(causal loop diagrams and simulation models)
Forecasting
Models
Articulate steps between program actions and results
Improve understanding about the possible effects of a policy over time
Focus on patterns of change over time (e.g., long
delays, worse before better)
Make accurate forecasts of key variables
Focus on precision of point predictions and confidence intervals
Safer,Healthier
Population BecomingVulnerable
Becoming nolonger vulnerable
VulnerablePopulation Becoming
Afflicted
Afflictedwithout
Complications DevelopingComplications
Targetedprotection
Primaryprevention
Secondaryprevention
Afflicted withComplications
Dying fromComplications
Tertiaryprevention
Society's HealthResponse
Generalprotection
Adverse LivingConditions
From: Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.
CDC Futures InitiativeReport from the Health Systems Workgroup
CDC Futures InitiativeReport from the Health Systems Workgroup
Figure 1 Health system dynamics
Public Work (organizing, governance, citizenship, mutual accountability)
Professional Work (customers, products, services)
more inter-organizationally complex, slower rate of improvement
organizationally complex, faster rate of improvement
FOR SELF INTEREST FOR OTHERS IN NEED
What Kinds of Work are Needed?What Kinds of Work are Needed?
Safer,Healthier
Population
VulnerablePopulationBecoming
Vulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingAfflicted
Afflicted withComplications
DevelopingComplications
Dying fromComplications
Primaryprevention
Secondaryprevention
Tertiaryprevention
Generalprotection
Targetedprotection
Society's HealthResponse
Adverse LivingConditions
PublicWork
Dependence on Living ConditionsDependence on Living Conditions
Corning PA. Presidential speech: the systems sciences in the year 3000. International Society of the Systems Sciences, 2000. Accessed April 23, 2002 at <http://www.complexsystems.org/commentaries/jul00.html>.
"Each of us has an array of basic needs that must, by and large,
be satisfied continuously. We cannot, for instance, do for very
long without fresh water, or waste elimination, or sleep.
Accordingly, each of us–individually and collectively–requires a
synergistic ‘package' of resources and suitable environmental
conditions. A society that can reliably provide this package will
thrive and possibly grow larger. But if even one of these needs
is not satisfied–if any part of the package is deficient–the entire
enterprise is likely to be threatened"
"Each of us has an array of basic needs that must, by and large,
be satisfied continuously. We cannot, for instance, do for very
long without fresh water, or waste elimination, or sleep.
Accordingly, each of us–individually and collectively–requires a
synergistic ‘package' of resources and suitable environmental
conditions. A society that can reliably provide this package will
thrive and possibly grow larger. But if even one of these needs
is not satisfied–if any part of the package is deficient–the entire
enterprise is likely to be threatened"
“Living conditions are the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic
circumstances and the physical environment – all of which can impact
upon health – and are largely outside of the immediate control of the individual.”
“Living conditions are the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic
circumstances and the physical environment – all of which can impact
upon health – and are largely outside of the immediate control of the individual.”
-- World Health Organization-- World Health Organization
Definition:Living Conditions
Definition:Living Conditions
World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.
Prerequisite Conditions for HealthPrerequisite Conditions for Health
World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.
World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.
Endorsed at all five world conferences on health promotion (1986-2000)
Endorsed at all five world conferences on health promotion (1986-2000)
Peace
Shelter
Education
Food
Peace
Shelter
Education
Food
Income
Stable eco-system
Sustainable resources
Social justice and equity
Income
Stable eco-system
Sustainable resources
Social justice and equity
Human Development FreedomsHuman Development Freedoms
Health
Education
Standard of living
Political participation
Social engagement
Physical security
Health
Education
Standard of living
Political participation
Social engagement
Physical security
Sen AK. Development as freedom. New York: Anchor books, 1999.
United Nations Development Programme. Human development report 2002: deepening democracy in a fragmented world. New York: Oxford University Press; 2002.
UNDP Human Development Index
UNDP Human Development Index
Seeing Conditions as FreedomsSeeing Conditions as Freedoms
Adverse living conditions are circumstances that inhibit people's freedom to be safe and healthy and develop their full potential
They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection)
Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions
Adverse living conditions are circumstances that inhibit people's freedom to be safe and healthy and develop their full potential
They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection)
Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions
Linking Living Conditions to FreedomsLinking Living Conditions to FreedomsHealthy State Freedom From… Selected Examples
Physical security Physical extremes Crash, fire, fall
Heat, cold
Radiation
Hazardous substances
Natural disaster
Infectious diseases
Peace Violence Homicide
Suicide
War
Rape
Minimal standard of living
Deprivation Malnutrition
Homelessness
Poverty
Joblessness
Overcrowding
Illiteracy
Inadequate education
Social engagement Disconnection Inequality
Injustice
Dependency
Incarceration
Runaway
Neglect
Stable organic processes
Impaired metabolism
Heart disease
Cancer
Stroke
Diabetes
Arthritis
Obesity
Mental/emotional balance
Impaired cognition or emotion
Depression
Anxiety
Attention deficit
Lack of recreation
Successful reproduction
Impaired reproduction
Infertility
Miscarriage
Birth defects
Infant mortality
Choice and Non-ChoiceChoice and Non-Choice
Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93.
“Choices are always made from among
alternatives presented by the social
environment, or by circumstances that were
themselves not chosen…When we recognize the
elements of non-choice in choice, we can escape
the contradiction between social causation and
individual responsibility and understand the
interactiveness of the two.”
“Choices are always made from among
alternatives presented by the social
environment, or by circumstances that were
themselves not chosen…When we recognize the
elements of non-choice in choice, we can escape
the contradiction between social causation and
individual responsibility and understand the
interactiveness of the two.”
Balancing Two Areas of EmphasisBalancing Two Areas of Emphasis
World of Providing…
• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…
Medical and Public Health Policy
DISEASE AND RISK MANAGEMENT
World of Transforming…
• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
Safer,Healthier
Population
VulnerablePopulationBecoming
Vulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingAfflicted
Afflicted withComplications
DevelopingComplications
Dying fromComplications
Primaryprevention
Secondaryprevention
Tertiaryprevention
Generalprotection
Targetedprotection
Society's HealthResponse
Adverse LivingConditions
PublicWork
On Protection and LeadershipOn Protection and Leadership
"How do you know," I asked, "that in
twenty years those things that you
consider special are still going to be
here?" At first they all raised their
hands but when they really digested
the question every single one of them
put their hands down. In the end,
there was not a single hand up. No
one could answer that question…”
"How do you know," I asked, "that in
twenty years those things that you
consider special are still going to be
here?" At first they all raised their
hands but when they really digested
the question every single one of them
put their hands down. In the end,
there was not a single hand up. No
one could answer that question…”
-- Nainoa Thompson-- Nainoa Thompson
Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.
Two Policy OrientationsTwo Policy Orientations
Adapted from: Hancock T. Beyond health care: from public health policy to healthy public policy. Can J Public Health 1985;76 Suppl 1:9-11.Adapted from: Hancock T. Beyond health care: from public health policy to healthy public policy. Can J Public Health 1985;76 Suppl 1:9-11.
Healthy Public Policy and Public Work Medical and Public Health Policy
Concerned chiefly with expanding people’s freedom to be safe and healthy
Concerned chiefly with preventing and alleviating specific diseases, managing complications, and delaying premature death or disability
Relies heavily on multiple, small-scale, local solutions, with low technology
Relies heavily on specific high-technology solutions, widely applied
Combines analyses into a broad systems view, transcending sector boundaries
Confines analyses to the health sector
Future-oriented (reacting to long-term dynamics)
Present-oriented (reacting to immediate events)
Questions the givens, focuses on plausible outcomes
Accepts the givens, focuses on probable outcomes
Evaluated first through simulation, then through implementation
Evaluated through implementation
Main resources are citizen leadership and broad-based public work (including that of professionals)
Main resources are money, professional expertise, and technology (often excluding citizen leadership)
Could the behavior of this system be modeled mentally, or with conventional epidemoiological methods
(e.g., logistic or multi-level regression)?
Could the behavior of this system be modeled mentally, or with conventional epidemoiological methods
(e.g., logistic or multi-level regression)?
How Do We Craft High Leverage Policies?How Do We Craft High Leverage Policies?
Safer,Healthier
Population
VulnerablePopulationBecoming
Vulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingAfflicted
Afflicted withComplications
DevelopingComplications
Dying fromComplications
Primaryprevention
Secondaryprevention
Tertiaryprevention
Generalprotection
Targetedprotection
Society's HealthResponse
Adverse LivingConditions
PublicWork
Dynamic Models Let Us Search for Policies with the Greatest LeverageDynamic Models Let Us Search for Policies with the Greatest Leverage
Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options: they provide added foresight
Such models open new avenues for planning and formally evaluating prevention policies
Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options: they provide added foresight
Such models open new avenues for planning and formally evaluating prevention policies
Prototype of a health system simulation modelPrototype of a health system simulation model
Re-Directing the Course of ChangeQuestions from System Modeling and Social Navigation
Re-Directing the Course of ChangeQuestions from System Modeling and Social Navigation
20202010
Prevalence of Diagnosed Diabetes, US
0
5
10
15
1980 1985 1990 1995 2000
Mill
ion
peop
le
Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.
How?
Why?
Where?
Who?
“Let me assure you, we will survive any crisis
that involves funding, political support,
popularity, or cyclic trends, but we can't
survive the internal crisis, if we become
provincial, focus totally on the short term, or
if we lose our philosophy of social justice.”
“Let me assure you, we will survive any crisis
that involves funding, political support,
popularity, or cyclic trends, but we can't
survive the internal crisis, if we become
provincial, focus totally on the short term, or
if we lose our philosophy of social justice.”
-- William Foege-- William Foege
Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.
Progress in Dynamic ModelingProgress in Dynamic Modeling
The Dynamics of Upstream and Downstream Why is it so hard for the health system to work upstream, and what can be done about it? (Milstein & Homer, with the CDC Futures Health System Workgroup)
The System-wide Drivers of Diabetes What are the system-wide drivers of type 2 diabetes incidence and progression, including other chronic illnesses, risk factors, and multiple types of prevention and protection programs?(CDC Diabetes System Modeling Project)
The Problem of Outside AssistanceWhat types of outside assistance are most effective in reducing the overall burden of affliction (unhealthy days) in communities with multiple afflictions? (Homer & Milstein 2002, 2004; web game)
The Dynamics of Upstream and Downstream Why is it so hard for the health system to work upstream, and what can be done about it? (Milstein & Homer, with the CDC Futures Health System Workgroup)
The System-wide Drivers of Diabetes What are the system-wide drivers of type 2 diabetes incidence and progression, including other chronic illnesses, risk factors, and multiple types of prevention and protection programs?(CDC Diabetes System Modeling Project)
The Problem of Outside AssistanceWhat types of outside assistance are most effective in reducing the overall burden of affliction (unhealthy days) in communities with multiple afflictions? (Homer & Milstein 2002, 2004; web game)
For Additional Informationhttp://www.cdc.gov/syndemics
Background on Dynamic Modeling Projects
Work in Progress
Background on Dynamic Modeling Projects
Work in Progress
Benefits of Game-Based LearningBenefits of Game-Based Learning
Formal means of evaluating options
Compressed time
Actions can be stopped or reversed
Experimental control of all conditions
Complete, undistorted, immediate results
Rehearse worse-before-better scenarios
Early warning of unintended effects
Opportunity to assemble stronger support
Formal means of evaluating options
Compressed time
Actions can be stopped or reversed
Experimental control of all conditions
Complete, undistorted, immediate results
Rehearse worse-before-better scenarios
Early warning of unintended effects
Opportunity to assemble stronger support
“Artful scenario spinning…ensures not that you are always right about the future but--better--that you are almost never wrong."
-- Stewart Brand
“Artful scenario spinning…ensures not that you are always right about the future but--better--that you are almost never wrong."
-- Stewart Brand
Progress in Dynamic ModelingProgress in Dynamic Modeling
Problem Focus Stage of Development
Outside assistance in communities with multiple afflictions
Most exploratory
Designed to explore interactions between afflictions, living conditions, and public strength
Dynamics of upstream and downstream health work
More empirically supported
Designed to understand an observed phenomenon, the 97% -- 3% split in health care expenditures
Dynamics of diabetes incidence and progression
Most empirically supported
Steps for Putting Maps in MotionSteps for Putting Maps in MotionIdentify a persistent problem that exists, in part, due to dynamic complexity (i.e., forces of feedback, delay, non-linearity, etc…)
Develop a preliminary dynamic hypothesis (i.e., what causal forces are at work?)
Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on available data; areas of uncertainty are noted and become the focus for sensitivity analysis)
Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time
Iteratively repeat the process, creating better hypotheses, better models, better policy insight, and more effective action
Identify a persistent problem that exists, in part, due to dynamic complexity (i.e., forces of feedback, delay, non-linearity, etc…)
Develop a preliminary dynamic hypothesis (i.e., what causal forces are at work?)
Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on available data; areas of uncertainty are noted and become the focus for sensitivity analysis)
Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time
Iteratively repeat the process, creating better hypotheses, better models, better policy insight, and more effective action
Why Is it So Hard to Work Upstream?A Preliminary Dynamic Hypothesis
Why Is it So Hard to Work Upstream?A Preliminary Dynamic Hypothesis
Upstream Prevention and Protection-----------------------------------Total 3%
Downstream Care and Management--------------------------------Total 97%
Brown R, Elixhauser A, Corea J, Luce B, Sheingod S. National expenditures for health promotion and disease prevention activities in the United States. Washington, DC: Battelle; Medical Technology Assessment and Policy Research Center; 1991. Report No.: BHARC-013/91-019.
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Health System DynamicsHealth System Dynamics
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Downstreamwork
Professionalconcern
Health System DynamicsHealth System Dynamics
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onprogression
-
Effect oncomplications
-
TertiaryPrevention
SecondaryPrevention
Downstreamwork
Professionalconcern
Health System DynamicsHealth System Dynamics
Safer,Healthier
Population
VulnerablePopulation
Becomingvulnerable
Becoming nolonger vulnerable
Afflictedwithout
ComplicationsBecomingafflicted
Afflicted withComplications
Developingcomplications
Dying fromComplications
Effect onprogression
-
Effect oncomplications
-
TertiaryPrevention
SecondaryPrevention
Vulnerable andAfflicted Popn
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
Publicwork
Health System DynamicsHealth System Dynamics
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 Popn
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
-
Publicwork
Health System DynamicsHealth System Dynamics
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 Popn
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
Citizen Involvementand Organizing
-
Publicwork
Health System DynamicsHealth System Dynamics
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 Popn
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
SocialDisparity
-
Citizen Involvementand Organizing
SocialDivision
-
Publicwork
Health System DynamicsHealth System Dynamics
Downstream lock-in: Delay in upstream effort guarantees continued growth in affliction prevalence and emphasis on treatment, which further delays upstream effort, as does mounting social disparity.
Health System DynamicsHealth System Dynamics
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 Popn
Upstreamwork
Downstreamwork
Professionalconcern
Publicconcern
AdverseLiving
Conditions
-
PublicStrength
SocialDisparity
-
Citizen Involvementand Organizing
SocialDivision
-
PublicworkInstitutional/organizational
emphasis on diseaserather than vulnerability
-
Prototype of a Dynamic Health System Simulation
Work in Progress
Prototype of a Dynamic Health System Simulation
Work in Progress
Building a Dynamic HypothesisBuilding a Dynamic Hypothesis
GeneralPopulation Vulnerability
onset
Vulnerabilityreduction
VulnerablePopulation Affliction
incidence
Afflictedwithout
Complications Afflictionprogression
afflicted percent of
Public healthresponse
Complicated
popn
-
General protectioneffect on vulnerability
onset
B General Protection
Targeted protectioneffect on vulnerability
reduction
B Targeted Protection
Afflicted withComplications
Death fromComplications
-
Secondary preventioneffect on progression
B
SecondaryPrevention
Primary preventioneffect on incidence
-
B
Primary Prevention
Tertiary preventioneffect on
complications
-
B
Treatment
Note: for this initial model, the system being modeled includes only a subset of the dynamics that were identified in the conceptual map.
Active Equations (01) Afflicted = Afflicted without Complications + Afflicted with Complications
(02) Afflicted with Complications = INTEG( Affliction progression - Death from Complications , 0)
(03) Afflicted without Complications = INTEG( Affliction incidence - Affliction progression , 0)
(04) Affliction incidence = Vulnerable Popn * Affliction incidence rate baseline * Primary prevention effect on incidence
(05) Affliction incidence rate baseline = 0.05
(06) Affliction progression = Afflicted without Complications * Affliction progression rate baseline * Secondary prevention effect on progression
(07) Affliction progression rate baseline = 0.1
(08) Complicated afflicted percent of popn = 100 * Afflicted with Complications / Total popn
(09) Complicated afflicted percent required to elicit maximum PH response = 20
(10) Complicated percent of afflicted = 100 * ZIDZ ( Afflicted with Complications , Afflicted )
(11) Complications death rate baseline = 0.1
Writing Differential EquationsWriting Differential Equations
(12) Death from Complications = Afflicted with Complications * Complications death rate baseline * Tertiary prevention effect on complications
(13) General Popn = INTEG( Net increase in genl popn + Vulnerability reduction - Vulnerability onset , Total popn initial * ( 100 - Vulnerable percent initial ) / 100)
(14) General protection effect from max PHR = 0.5
(15) General protection effect on vulnerability onset = 1 - ( 1 - General protection effect from max PHR ) * Public health response / 100
(16) Net increase in genl popn = Death from Complications * ( 1 - Vulnerable percent of nonafflicted / 100)
(17) Net increase in vulnerable popn = Death from Complications * Vulnerable percent of nonafflicted / 100
(18) Nonafflicted = General Popn + Vulnerable Popn
(19) Primary prevention effect from max PHR = 0.5
(20) Primary prevention effect on incidence = 1 - ( 1 - Primary prevention effect from max PHR ) * Public health response / 100
(21) Public health response = DELAY1I ( 100 * MIN ( 1, Complicated afflicted percent of popn / Complicated afflicted percent required to elicit maximum PH response ) , Time for public health to respond to affliction prevalence , 0)
Writing Differential EquationsWriting Differential Equations
(22) Secondary prevention effect from max PHR = 0.5
(23) Secondary prevention effect on progression = 1 - ( 1 - Secondary prevention effect from max PHR ) * Public health response / 100
(24) Targeted protection effect from max PHR = 2
(25) Targeted protection effect on vulnerability reduction = 1 + ( Targeted protection effect from max PHR - 1) * Public health response / 100
(26) Tertiary prevention effect from max PHR = 0.5
(27) Tertiary prevention effect on complications = 1 - ( 1 - Tertiary prevention effect from max PHR ) * Public health response / 100
(28) Time for public health to respond to affliction prevalence = 2
(29) Total popn = Nonafflicted + Afflicted
(30) Total popn initial = 100000
(31) Vulnerability onset = General Popn * Vulnerability onset rate baseline * General protection effect on vulnerability onset
(32) Vulnerability onset rate baseline = 0.05
Writing Differential EquationsWriting Differential Equations
(33) Vulnerability reduction = Vulnerable Popn * Vulnerability reduction rate baseline * Targeted protection effect on vulnerability reduction
(34) Vulnerability reduction rate baseline = 0.07
(35) Vulnerable percent initial = 10
(36) Vulnerable percent of nonafflicted = 100 * Vulnerable Popn / Nonafflicted
(37) Vulnerable Popn = INTEG( Net increase in vulnerable popn + Vulnerability onset - Affliction incidence - Vulnerability reduction , Total popn initial * Vulnerable percent initial / 100)
Writing Differential EquationsWriting Differential Equations
Parameter Assumption
Population Characteristics
Total population initially 100,000
Percent afflicted initially 0%
Percent vulnerable initially 10%
Developing Assumptions For Response Scenarios
Developing Assumptions For Response Scenarios
Parameter Assumption
Baseline Epidemiological Characteristics
Vulnerability onset rate (% per year among general pop) 5%
Vulnerability reduction rate (% per year among vulnerable) 7%
Affliction incidence rate (% per year among vulnerable) 5%
Affliction progression rate (% per year among afflicted without complications)
10%
Complications death rate (% per year among afflicted with complications)
10%
Developing Assumptions For Response Scenarios
Developing Assumptions For Response Scenarios
Parameter Assumption
Health System Characteristics
Complicated affliction prevalence required to elicit maximum health system response (lower prevalence elicits proportionally smaller response)
20%
Time for organizing a health system response to complicated affliction prevalence
2 years
Developing Assumptions For Response Scenarios
Developing Assumptions For Response Scenarios
Parameter Assumption
Effect of Health System Responses
Tertiary prevention effect on deaths from complications ?
Secondary prevention effect on affliction progression ?
Primary prevention effect on affliction incidence ?
Targeted protection effect on vulnerability reduction ?
General protection effect on vulnerability onset ?
Making Decisions About How to RespondMaking Decisions About How to Respond
Response Scenario
Effect of Health System Response on…
40-Year Simulation Results
DeathsAffliction Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1
Prev 3 0.5 1 1 1 1
Prev 2+3 0.5 0.5 1 1 1
Prev 1+2+3 0.5 0.5 0.5 1 1
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5
Developing a Scenario-based Research DesignDeveloping a Scenario-based Research Design
Putting the System in MotionPutting the System in Motion
Afflicted with Complications
20,000
10,000
0
0 4 8 12 16 20 24 28 32 36 40Time
Afflicted with Complications : NoRespAfflicted with Complications : Prev3Afflicted with Complications : Prev23Afflicted with Complications : Prev123Afflicted with Complications : Prev123Prot2Afflicted with Complications : Prev123Prot12
Interpreting Behavior Over TimeInterpreting Behavior Over Time
Response Scenario
Effect of Health System Response on…
40-Year Simulation Results
DeathsAffliction Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1 11%
Prev 3 0.5 1 1 1 1 14%
Prev 2+3 0.5 0.5 1 1 1 12%
Prev 1+2+3 0.5 0.5 0.5 1 1 11%
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1 10%
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5 9%
Interpreting Behavior Over TimeInterpreting Behavior Over Time
Vulnerable Popn
40,000
32,000
24,000
16,000
8,000
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time
Vulnerable Popn : NoRespVulnerable Popn : Prev3Vulnerable Popn : Prev23Vulnerable Popn : Prev123Vulnerable Popn : Prev123Prot2Vulnerable Popn : Prev123Prot12
Interpreting Behavior Over TimeInterpreting Behavior Over Time
Response Scenario
Effect of Health System Response on…
40-Year Simulation Results
DeathsAffliction Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1 11% 25%
Prev 3 0.5 1 1 1 1 14% 24%
Prev 2+3 0.5 0.5 1 1 1 12% 24%
Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26%
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1 10% 22%
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5 9% 19%
Interpreting Behavior Over TimeInterpreting Behavior Over Time
Public health response
80
64
48
32
16
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time
Public health response : NoRespPublic health response : Prev3Public health response : Prev23Public health response : Prev123Public health response : Prev123Prot2Public health response : Prev123Prot12
Interpreting Behavior Over TimeInterpreting Behavior Over Time
Response Scenario
Effect of Health System Response on…
40-Year Simulation Results
DeathsAffliction Progress
Affliction Incidence
Vulnerable Reduction
Vulnerable Onset
Percent
Afflicted w/ Complication
(T0 = 0%)
Percent Vulnerable
(T0 = 10%)
PH Response
(T0 = 0%)
No Response 1 1 1 1 1 11% 25% 0%
Prev 3 0.5 1 1 1 1 14% 24% 69%
Prev 2+3 0.5 0.5 1 1 1 12% 24% 60%
Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26% 53%
Prev 1+2+3
Prot 20.5 0.5 0.5 2 1 10% 22% 50%
Prev 1+2+3 +
Prot 1+20.5 0.5 0.5 2 0.5 9% 19% 47%
Interpreting Behavior Over TimeInterpreting Behavior Over Time
Diabetes System Modeling Project Work in Progress
Diabetes System Modeling Project Work in Progress
Forecast of Diabetes PrevalenceForecast of Diabetes Prevalence
Prevalence of Diagnosed Diabetes, US
0
10
20
30
40
1980 1990 2000 2010 2020 2030 2040 2050
Mill
ion
pe
op
le
Historical Data: CDC DDT and NCCDPHP. (Change in measurement in 1996).Model Forecast: Honeycutt et al. 2003, "A Dynamic Markov model…"
HistoricalData
ModelForecast
Key Constants• Incidence rates (%/yr)• Death rates (%/yr)• Diagnosed fractions(Based on year 2000 data, per demographic segment)
Focusing on the More Modifiable Drivers
Focusing on the More Modifiable Drivers
Prevalence of Diagnosed Diabetes, USHistorical and Forecasted
0
10
20
30
40
1980 1990 2000 2010 2020 2030 2040 2050
Mill
ion
peop
le
Historical Data: CDC DDT and NCCDPHP. (Change in measurement in 1996).Model Forecast: Honeycutt et al. 2003, "A Dynamic Markov model…"
Due to Population Growth
Due to Changes in Prevalence Fractions
Due to Changes in Demographic Mix
54%
20%
26%
Re-Directing the Course of ChangeRe-Directing the Course of Change
20202010
Prevalence of Diagnosed Diabetes, US
0
5
10
15
1980 1985 1990 1995 2000
Mill
ion
peop
le
Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.
How?
Why?
Where?
Who?
Diabetes System Modeling ProjectDiabetes System Modeling Project
CDC-Wide Champions
Observers and Other Constituents
Initial Model Conceptualization Team
Program Branch
NCCDPHPSenior Staff
Office of Director
Epidemiology BranchCardiovascular
Health
Nutrition and Physical Activity
Adult andCommunity Health
Adolescent and School Health
Public Health
Practice
Division of Diabetes Translation
DynamicModelingExperts
Smoking and Health
Non-Diabetics
Diabetics
Diabetes onset
Diabetes Population FlowsDiabetes Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
Progression ofDx S1 to S2
S2 deaths
High RiskNot
Prediabetic
UndiagnosedStage 1
Diabetics
Diagnosis ofS1 diabetes
Progression ofUndx S1 to S2
GeneralPopulation
BecomeHigh Risk
Rehab ofHigh Risk
UndiagnosedPrediabetic
DiagnosedPrediabetic
Diabetes onsetfrom Undx PreD
Diabetes onsetfrom Dx PreD
Diagnosis ofPrediabetes
Prediabetesonset
Rehab ofUndx PreD
Rehab ofDx PreD
Diabetics
Non-Diabetics
Diabetes Population FlowsDiabetes Population Flows
Diabetes Population FlowsDiabetes Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
Progression ofDx S1 to S2
S2 deaths
High RiskNot
Prediabetic
UndiagnosedStage 1
Diabetics
Diagnosis ofS1 diabetes
Progression ofUndx S1 to S2
GeneralPopulation
BecomeHigh Risk
Rehab ofHigh Risk
UndiagnosedPrediabetic
DiagnosedPrediabetic
Diabetes onsetfrom Undx PreD
Diabetes onsetfrom Dx PreD
Diagnosis ofPrediabetes
Prediabetesonset
Rehab ofUndx PreD
Rehab ofDx PreD
Diabetics
Non-Diabetics
DiagnosedStage 1
Diabetics
Stage 2Diabetics
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
Tertiary Prevention: Disease Management for Stage 2 Diabetics
Diabetics
Non-Diabetics
Diabetes Population FlowsDiabetes Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
Progression ofDx S1 to S2
S2 deaths
High RiskNot
Prediabetic
UndiagnosedStage 1
Diabetics
Diagnosis ofS1 diabetes
Progression ofUndx S1 to S2
GeneralPopulation
BecomeHigh Risk
Rehab ofHigh Risk
UndiagnosedPrediabetic
DiagnosedPrediabetic
Diabetes onsetfrom Undx PreD
Diabetes onsetfrom Dx PreD
Diagnosis ofPrediabetes
Prediabetesonset
Rehab ofUndx PreD
Rehab ofDx PreD
Secondary Prevention: Screening for Diabetes & Disease Mgmt for Stage 1 Diabetics
Diabetics
Non-Diabetics
Diabetes Population FlowsDiabetes Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
Progression ofDx S1 to S2
S2 deaths
High RiskNot
Prediabetic
UndiagnosedStage 1
Diabetics
Diagnosis ofS1 diabetes
Progression ofUndx S1 to S2
GeneralPopulation
BecomeHigh Risk
Rehab ofHigh Risk
UndiagnosedPrediabetic
DiagnosedPrediabetic
Diabetes onsetfrom Undx PreD
Diabetes onsetfrom Dx PreD
Diagnosis ofPrediabetes
Prediabetesonset
Rehab ofUndx PreD
Rehab ofDx PreD
Primary Prevention: Screening for Prediabetes & Nutrition/Activity for High Risk Individuals
Diabetics
Non-Diabetics
Diabetes Population FlowsDiabetes Population Flows
Targeted Protection: Risk Factor Elimination for High Risk Individuals
Diabetics
Non-Diabetics
Diabetes Population FlowsDiabetes Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
Progression ofDx S1 to S2
S2 deaths
High RiskNot
Prediabetic
UndiagnosedStage 1
Diabetics
Diagnosis ofS1 diabetes
Progression ofUndx S1 to S2
GeneralPopulation
BecomeHigh Risk
Rehab ofHigh Risk
UndiagnosedPrediabetic
DiagnosedPrediabetic
Diabetes onsetfrom Undx PreD
Diabetes onsetfrom Dx PreD
Diagnosis ofPrediabetes
Prediabetesonset
Rehab ofUndx PreD
Rehab ofDx PreD
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
General Protection: Changing Risk Conditions of the General and High Risk Populations
Diabetics
Non-Diabetics
Diabetes Population FlowsDiabetes Population Flows
Where is the Greatest Leverage?Comparing Program Strategies,
Alone and in Combination
Where is the Greatest Leverage?Comparing Program Strategies,
Alone and in Combination
Diabetes education for the public
Diabetes education for providers
Weight reduction programs for the obese
Resources for diabetes disease management
Resources for glycemic screening
Facilitating greater food choice
Facilitating greater availability of affordable health care
Facilitating greater social and cultural support for the underserved
Facilitating improvements in built environment and public safety
Facilitating more work opportunities
Others….
Diabetes education for the public
Diabetes education for providers
Weight reduction programs for the obese
Resources for diabetes disease management
Resources for glycemic screening
Facilitating greater food choice
Facilitating greater availability of affordable health care
Facilitating greater social and cultural support for the underserved
Facilitating improvements in built environment and public safety
Facilitating more work opportunities
Others….
Conducting Policy Experiments Conducting Policy Experiments
Population Breakdown Based on National Statistics
Population Breakdown Based on National Statistics
Total Population
Diabetics 6%
22%
Status within Diabetics
Undiagnosed 32%
Diagnosed stage 1 diabetics 35%
Diagnosed stage 2 diabetics 33%
Within the high risk group, we calculate 25-45% have IGT and 33-60% are Prediabetic (IGT or IFG)*
* Lower numbers based on Benjamin et al. 2003, higher numbers based on NIDDK estimates. IGT: Impaired Glucose Tolerance, 2 hr. non-fasting, 140-199 mg/dl; IFG: Impaired Fasting Glucose, 110-125
mg/dl
Generalpopulation
72%
High risk22%
Data Sources for Initial CalibrationData Sources for Initial CalibrationHigh Risk Population, Incidence, Prevalence, Deaths
“National Diabetes Statistics”: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm“Prevalence of Selected Chronic Conditions: United States, 1990-1992”: www.cdc.gov/nchs/data/series/sr_10/sr10_194.pdf“Healthy People 2000 Review, 1997”: www.cdc.gov/nchs/data/hp2000/hp2k97.pdf“Deaths: Preliminary Data for 2000”: www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf“Estimated number of adults with prediabetes in the U.S. in 2000: Opportunities for prevention”, Benjamin SM et al (DDT/CDC), Diabetes Care 26: 645-9, 2003.“A Dynamic Markov Model for Forecasting Diabetes Prevalence in the United States through 2050”, Honeycut AA et al. (DDT/CDC), Health Care Mgmt Sci 6: 155-164, 2003.
Complications and Benefits of Control“Model of Complications of NIDDM--1. Model Construction and Assumptions”, Eastman RC et al, Diabetes Care 20: 725-734, 1997.“Model of Complications of NIDDM--2. Analysis of the Health Benefits and Cost-Effectiveness of Treating NIDDM with the Goal of Normoglycemia”, Eastman RC et al., Diabetes Care 20: 735-744, 1997.“The Prevention or Delay of Type 2 Diabetes”, position statement from ADA and NIDDK, Diabetes Care 25: 742-749, 2002“Effect of Improved Glycemic Control on Health Care Costs and Utilization”, EH Wagner et al., JAMA 285: 182-189, 2001“Health Economic Benefits and Quality of Life During Improved Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Randomized, Controlled Double-Blind Trial”, Testa MA and Simonson DC, JAMA, 280: 1490-6, 1998
High Risk Population, Incidence, Prevalence, Deaths“National Diabetes Statistics”: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm“Prevalence of Selected Chronic Conditions: United States, 1990-1992”: www.cdc.gov/nchs/data/series/sr_10/sr10_194.pdf“Healthy People 2000 Review, 1997”: www.cdc.gov/nchs/data/hp2000/hp2k97.pdf“Deaths: Preliminary Data for 2000”: www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf“Estimated number of adults with prediabetes in the U.S. in 2000: Opportunities for prevention”, Benjamin SM et al (DDT/CDC), Diabetes Care 26: 645-9, 2003.“A Dynamic Markov Model for Forecasting Diabetes Prevalence in the United States through 2050”, Honeycut AA et al. (DDT/CDC), Health Care Mgmt Sci 6: 155-164, 2003.
Complications and Benefits of Control“Model of Complications of NIDDM--1. Model Construction and Assumptions”, Eastman RC et al, Diabetes Care 20: 725-734, 1997.“Model of Complications of NIDDM--2. Analysis of the Health Benefits and Cost-Effectiveness of Treating NIDDM with the Goal of Normoglycemia”, Eastman RC et al., Diabetes Care 20: 735-744, 1997.“The Prevention or Delay of Type 2 Diabetes”, position statement from ADA and NIDDK, Diabetes Care 25: 742-749, 2002“Effect of Improved Glycemic Control on Health Care Costs and Utilization”, EH Wagner et al., JAMA 285: 182-189, 2001“Health Economic Benefits and Quality of Life During Improved Glycemic Control in Patients with Type 2 Diabetes Mellitus: A Randomized, Controlled Double-Blind Trial”, Testa MA and Simonson DC, JAMA, 280: 1490-6, 1998
One benefit of the modeling process can be knowledge integrationOne benefit of the modeling process can be knowledge integration
Response Scenario
Effect of Health System Response on…
Controled Fraction of
S2
Controled Fraction of
S1
Diabetes Diagnosis
Rate
Onset Rate for Dx PreD
Onset Rate for
UnDx PreD
PreD Diagnosis
Rate
PreD Onset Rate
Rehab of Dx PreD Rate
Rehab of High Risk UnDx PreD Rate
Become High Risk Rate
Steady State .2 .2 .06 .025 .045 .04 .065 .06 .03 .02
Prev 3 .5 " " " " " " " " "
Prev 2+3 .5 .5 .12 " " " " " " "
Prev 1+2+3 .5 .5 .12 .020 .040 .08 .55 " " "
Prev 2+3
Prot 2.5 .5 .12 " " " " .10 .05 "
Prev 1+2+3 +
Prot 1+2.5 .5 .12 .020 .040 .08 .55 .10 .05 .01
Developing a Scenario-based Research DesignDeveloping a Scenario-based Research Design
Model Tests Start in a Steady-StateModel Tests Start in a Steady-State
The model is initialized in a steady state or “dynamic equilibrium”
No change in total population: Births = Total deaths
Every population stock has inflows exactly cancelled by outflows
In the base (“flatline”) run, all input time series are unchanging
Any changes in the time series inputs (pink) will disturb the steady state and cause the population system to move toward a new equilibrium
By putting the model in an initial equilibrium we are able to examine the effects of changes in the time series inputs in isolation from general population trends (which will be added in a future version)
The model is initialized in a steady state or “dynamic equilibrium”
No change in total population: Births = Total deaths
Every population stock has inflows exactly cancelled by outflows
In the base (“flatline”) run, all input time series are unchanging
Any changes in the time series inputs (pink) will disturb the steady state and cause the population system to move toward a new equilibrium
By putting the model in an initial equilibrium we are able to examine the effects of changes in the time series inputs in isolation from general population trends (which will be added in a future version)
Interpreting Behavior Over TimeInterpreting Behavior Over TimeS2 complications deaths
600,000
300,000
0
0 4 8 12 16 20 24 28 32 36 40Time
S2 complications deaths : prev123prot12S2 complications deaths : prot12prev1S2 complications deaths : prev23S2 complications deaths : prev3S2 complications deaths : Steady state
Interpreting Behavior Over TimeInterpreting Behavior Over TimeProgression of Diagnosed S1 to S2
600,000
480,000
360,000
240,000
120,000
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time
Progression of Diagnosed S1 to S2 : prev123prot12 people per yearProgression of Diagnosed S1 to S2 : prot12prev1 people per yearProgression of Diagnosed S1 to S2 : prev23 people per yearProgression of Diagnosed S1 to S2 : prev3 people per yearProgression of Diagnosed S1 to S2 : Steady state people per year
Health Care & Public Health Agency Capacity
• Provider supply• Provider understanding, competence• Provider location• System integration• Cost of care• Insurance coverage
Population Flows
DiagnosedStage 1
Diabetics
Stage 2Diabetics
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
DRAFT: Diabetes System Sector Sketch (December 4-5, 2003)DRAFT: Diabetes System Sector Sketch (December 4-5, 2003)
Personal Capacity
• Understanding• Motivation• Social support• Literacy• Physio-cognitive function• Life stages
Metabolic Stressors
• Nutrition• Physical activity• Stress
• Baseline Flows
Health Care Utilization
• Ability to use care (match of patients and providers, language, culture)• Openness to/fear of screening• Self-management, monitoring
• Percent of patients screened• Percent of people with diabetes under control
Civic Participation
• Social cohesion• Responsibility for others
Forces Outside the Community
• Macroeconomy, employment• Food supply• Advertising, media• National health care• Racism• Transportation policies• Voluntary health orgs• Professional assns• University programs• National coalitions
Local Living Conditions
• Availability of good/bad food• Availability of phys activity• Comm norms, culture (e.g., responses to racism, acculturation)• Safety• Income• Transportation• Housing• Education
Included in version 1
Not included in version 1
How Does Outside Assistance Affect Communities Facing Multiple Afflictions?
Work in Progress
How Does Outside Assistance Affect Communities Facing Multiple Afflictions?
Work in Progress
What Are the Dynamics of Outside Assistance in Communities Facing Multiple Afflictions?
A Preliminary Dynamic Hypothesis
What Are the Dynamics of Outside Assistance in Communities Facing Multiple Afflictions?
A Preliminary Dynamic Hypothesis
KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop
Afflictionprevalence &
burden
Adverseliving
conditions
Effort to alleviate andprevent affliction
Effort to improveliving conditions
R1
R3a
R4a
R4b
B1b
B1a
Communitystrength
Outside assistance toalleviate and prevent
affliction
Outside assistanceto improve living
conditions
R2b
At-risk fraction
Afflictioncross-impacts
Social disparity
R2a Public work fraction
Outside assistance tobuild community
strength
United efforts
R2c
Magnitude ofefforts
Divided efforts
R3b
Afflictionprevalence& burden
Adverseliving
conditions
Publicstrength
R1
At-risk fraction
Afflictioncross-impacts
Effort to alleviate andprevent affliction
B1a
Effort to improveliving conditions
B1b
Effort to build public strength
B1c
Social disparityR2c
R2b
R2a
R3a
Public work fraction
United efforts
Divided efforts
R3b Magnitude ofameliorative efforts
R3c
R3d
Outside assistance toalleviate and prevent
affliction
Outside assistanceto improve living
conditions
Outside assistance to build public
strength
KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop
About the Feedback LoopsAbout the Feedback LoopsSyndemic: Each affliction increases vulnerability to other afflictions, thereby amplifying the effect of increases or decreases in the prevalence of individual afflictions.
Community Response: Community residents make efforts to fight affliction and adverse living conditions in response to their prevalence, and to build greater public strength when it is perceived as low. Outside assistance may bolster such efforts.
Social Disparity and Public Strength: These efforts, especially those to fight adverse living conditions, are greater in magnitude when citizens are strong and unified through democratic public institutions. But public strength is hindered by social disparity, which, in turn, is made worse by the very afflictions and adverse living conditions the efforts are trying to fight.
Public Strength and Public Work: Public strength is also affected by the efforts themselves. When problems spread in a community with strong democratic institutions, a united response (public work) reinforces the community’s strength. Conversely, when problems spread in a community with weaker democratic institutions, a divided response (consisting of only professional work) reinforces the community’s weakness. Outside assistance given to a weaker community for problem fighting may amplify the divided response and undermine the community’s internal response capability. Outside assistance to build public strength may prepare the residents to make a more united response.
Syndemic: Each affliction increases vulnerability to other afflictions, thereby amplifying the effect of increases or decreases in the prevalence of individual afflictions.
Community Response: Community residents make efforts to fight affliction and adverse living conditions in response to their prevalence, and to build greater public strength when it is perceived as low. Outside assistance may bolster such efforts.
Social Disparity and Public Strength: These efforts, especially those to fight adverse living conditions, are greater in magnitude when citizens are strong and unified through democratic public institutions. But public strength is hindered by social disparity, which, in turn, is made worse by the very afflictions and adverse living conditions the efforts are trying to fight.
Public Strength and Public Work: Public strength is also affected by the efforts themselves. When problems spread in a community with strong democratic institutions, a united response (public work) reinforces the community’s strength. Conversely, when problems spread in a community with weaker democratic institutions, a divided response (consisting of only professional work) reinforces the community’s weakness. Outside assistance given to a weaker community for problem fighting may amplify the divided response and undermine the community’s internal response capability. Outside assistance to build public strength may prepare the residents to make a more united response.
Syndemics Simulation Game http://broadcast.forio.com/sims/syndemic2003/
Four Scenarios for Affliction Burden
Development of a SyndemicDevelopment of a Syndemic
12
10
8
6
4
0 2 4 6 8 10 12 14 16 18 20Time (years)
Affliction burden : GBasicAffliction burden : GMARCIbAffliction burden : GBALCbAffliction burden : GBCSb
Basic scenario: Poor living conditions, weak community, intertwined afflictions
Weaker cross-impacts among afflictions
Better living conditions
Greater community strength
Avg unhealthy days per person per month
Evaluating Policy ScenariosEvaluating Policy Scenarios
Focus assistance on…
Fighting affliction
Improving adverse living conditions
Building public strength
Focus assistance on…
Fighting affliction
Improving adverse living conditions
Building public strength
Different proportions
Different combinations
Different sequences
Different proportions
Different combinations
Different sequences
Alternative Investment StrategiesAlternative Investment Strategies
Public Health Programming Social Programming Democratic Organizing
12
10
8
6
4
0 2 4 6 8 10 12 14 16 18 20Time (years)
Affliction burden : BasicOptAffliction burden : BasicAF111Affliction burden : BasicLC111Affliction burden : BasicCS111
Comparing Affliction Burden under Basic Setting and Four Different Assistance Schemes
Comparing Affliction Burden under Basic Setting and Four Different Assistance Schemes
Affliction assistance only “AF111”Conditions assistance only “LC111”
Strength assistance only “CS111”
Optimal assistance scheme “CS1AF11”
Avg affliction burden T4-T20:8.18.58.88.3
Policy HypothesesInvest Early in Building Strength
Policy HypothesesInvest Early in Building Strength
The first priority of philanthropies and government in addressing communities that are weak and struggling against multiple afflictions should be to assist in building public strength (enabling a greater degree of citizen-led public work), perhaps even before substantial assistance is provided for direct fighting of prevalent diseases.
The first priority of philanthropies and government in addressing communities that are weak and struggling against multiple afflictions should be to assist in building public strength (enabling a greater degree of citizen-led public work), perhaps even before substantial assistance is provided for direct fighting of prevalent diseases.
Policy HypothesesBeware the Side Effects of Outside
Assistance Related to Living Conditions
Policy HypothesesBeware the Side Effects of Outside
Assistance Related to Living Conditions
Outside assistance aimed directly at improving living conditions may often be insufficiently cost-effective, due to time lags and unintended side effects, to warrant making such assistance a high priority in the absence of widespread citizen participation
Outside assistance aimed directly at improving living conditions may often be insufficiently cost-effective, due to time lags and unintended side effects, to warrant making such assistance a high priority in the absence of widespread citizen participation
Structural Reasons for Policy Resistance
Structural Reasons for Policy Resistance
Problem-fighting programs may have perverse effects on public strength when the community residents are weak and divided to begin with
Problem-fighting programs may have perverse effects on public strength when the community residents are weak and divided to begin with