An Introduction to Syndemics: Implications for Health Promotion
An Introduction to Syndemics: Implications for Health Promotion
Introduction to Health Promotion (PH 7016)Georgia State University
April 19, 2006Atlanta, GA
Introduction to Health Promotion (PH 7016)Georgia State University
April 19, 2006Atlanta, GA
Bobby Milstein
Syndemics Prevention NetworkCenters for Disease Control and Prevention
[email protected]://www.cdc.gov/syndemics
Bobby Milstein
Syndemics Prevention NetworkCenters for Disease Control and Prevention
[email protected]://www.cdc.gov/syndemics
“Let me assure you, we will survive any
crisis that involves funding, political
support, popularity, or cyclic trends,
but we can't survive the internal crisis,
if we become provincial, focus totally
on the short term, or if we lose our
philosophy of social justice.”
“Let me assure you, we will survive any
crisis that involves funding, political
support, popularity, or cyclic trends,
but we can't survive the internal crisis,
if we become provincial, focus totally
on the short term, or if we lose our
philosophy of social justice.”
-- William Foege-- William Foege
Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.
What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice?
What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice?
What approaches to public health work may help us to recognize and overcome these pitfalls?
What approaches to public health work may help us to recognize and overcome these pitfalls?
What single word best conveys the message of this report?
What single word best conveys the message of this report?
Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988
Diseases of DisarrayDiseases of Disarray
Hardening of the categories
Tension headache between treatment and prevention
Hypocommitment to training
Cultural incompetence
Political phobia
Input obsession
Hardening of the categories
Tension headache between treatment and prevention
Hypocommitment to training
Cultural incompetence
Political phobia
Input obsession
Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.
Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.
New Word for a Familiar PhenomenonNew Word for a Familiar Phenomenon
Singer M, Snipes C. Generations of suffering: experiences of a treatment program for substance abuse during pregnancy. Journal of Health Care for the Poor and Underserved 1992;3(1):222-34.
Singer M. 1994. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Social Science and Medicine 39(7): 931-948.
Singer M. 1996. A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology 24(2): 99-110.
Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 2003;17(4):423-441.
“We have introduced the term ‘syndemic’ to
refer to the set of synergistic or intertwined
and mutually enhancing health and social
problems facing the urban poor. Violence,
substance abuse, and AIDS, in this sense, are
not concurrent in that they are not completely
separable phenomena.”
“We have introduced the term ‘syndemic’ to
refer to the set of synergistic or intertwined
and mutually enhancing health and social
problems facing the urban poor. Violence,
substance abuse, and AIDS, in this sense, are
not concurrent in that they are not completely
separable phenomena.”
-- Merrill Singer-- Merrill Singer
What was Singer doing?
What are the implications for public health work?
What principles and methodologies support this perspective (scientifically, politically, morally)?
What effects do these ways of thinking and acting have on individuals and in the world at large?
What was Singer doing?
What are the implications for public health work?
What principles and methodologies support this perspective (scientifically, politically, morally)?
What effects do these ways of thinking and acting have on individuals and in the world at large?
What Does it Mean to Approach Public Health Work from a Syndemic Orientation?
What Does it Mean to Approach Public Health Work from a Syndemic Orientation?
Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. <http://www.cdc.gov/syndemics>.
Ongoing study of innovations in public health work
Member network includes
419 individuals
280 organizations
19 countries
Ongoing study of innovations in public health work
Member network includes
419 individuals
280 organizations
19 countries
Starting PremisesStarting Premises
Public health work has changed significantly since its formalization in the 19th century, and even today it is poised for further transformation
It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match
We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, and what we value
Public health work has changed significantly since its formalization in the 19th century, and even today it is poised for further transformation
It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match
We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, and what we value
Plan for TodayPlan for Today
Explore the meaning and implications of a syndemic orientation
Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work
Illustrate how system dynamics maps and simulation models can support innovative thinking and action
Explore the meaning and implications of a syndemic orientation
Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work
Illustrate how system dynamics maps and simulation models can support innovative thinking and action
Epi·demic Epi·demic The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people
Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“
Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people
Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“
Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.
“Public death was first recognized as a matter of civilized concern
in the nineteenth century, when some public health workers
decided that untimely death was a question between men and
society, not between men and God….Since then, and for that
reason, millions of lives have been saved….The pioneers of public
health did not change nature, or men, but adjusted the active
relationship of men to certain aspects of nature so that the
relationship became one of watchful and healthy respect.
“Public death was first recognized as a matter of civilized concern
in the nineteenth century, when some public health workers
decided that untimely death was a question between men and
society, not between men and God….Since then, and for that
reason, millions of lives have been saved….The pioneers of public
health did not change nature, or men, but adjusted the active
relationship of men to certain aspects of nature so that the
relationship became one of watchful and healthy respect.
Public Health Began as Public WorkPublic Health Began as Public Work
-- Gil Elliot-- Gil Elliot
Syn·demic Syn·demic
The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena
It acknowledges relationships and signals a commitment to studying health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways
The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena
It acknowledges relationships and signals a commitment to studying health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways
Confounding
Connecting*
Synergism
Syndemic
Events
Systems
Co-occurring
* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping
Changing (and Accumulating) Ideas in Causal Theory
What accounts for poor population health?
Changing (and Accumulating) Ideas in Causal Theory
What accounts for poor population health?
God’s will
Humors, miasma, ether
Poor living conditions, immorality (sanitation)
Single disease, single cause (germ theory)
Single disease, multiple causes (heart disease)
Single cause, multiple diseases (tobacco)
Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)
Dynamic feedback among afflictions, living conditions, and public strength (syndemic)
God’s will
Humors, miasma, ether
Poor living conditions, immorality (sanitation)
Single disease, single cause (germ theory)
Single disease, multiple causes (heart disease)
Single cause, multiple diseases (tobacco)
Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)
Dynamic feedback among afflictions, living conditions, and public strength (syndemic)
1880
1950
1960
1980
2000
1840
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Seeing SyndemicsSeeing Syndemics
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and other 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 other citizens)
“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
Placing Health in a Wider Set of Relationships
Placing Health in a Wider Set of Relationships
Health
LivingConditions
PublicStrength
A syndemic orientation is one of a few approaches that includes within it our power to respond
A syndemic orientation is one of a few approaches that includes within it our power to respond
A Philosophy of MeansA Philosophy of Means
“About the ideal goal of human effort there
exists in our civilization and, for nearly
thirty centuries, there has existed a very
general agreement….Not so with regard to
the roads which lead to that goal. Here
unanimity and certainty give place to utter
confusion, to the clash of contradictory
opinions, dogmatically held and acted upon
with the violence of fanaticism.”
“About the ideal goal of human effort there
exists in our civilization and, for nearly
thirty centuries, there has existed a very
general agreement….Not so with regard to
the roads which lead to that goal. Here
unanimity and certainty give place to utter
confusion, to the clash of contradictory
opinions, dogmatically held and acted upon
with the violence of fanaticism.”
-- Aldous Huxley-- Aldous Huxley
Huxley A. Ends and means: an inquiry into the nature of ideals and into methods employed for their realization. New York, NY: Harper, 1937.
A Philosophy of MeansA Philosophy of Means
“Social and political theory
have neglected the central
question of means, and,
therefore, the problem of
inevitable conflict.”
“Social and political theory
have neglected the central
question of means, and,
therefore, the problem of
inevitable conflict.”
-- Joan Bondurant-- Joan Bondurant
Bondurant JV. Conquest of violence: the Gandhian philosophy of conflict. New rev. ed. Princeton NJ: Princeton University Press, 1988.
Toward a Complementary Science of Relationships
Toward a Complementary Science of Relationships
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses
Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
Scott JC. Seeing like a state: how certain schemes to improve the human condition have failed. New Haven ; London: Yale University Press, 1999.
"Certain forms of knowledge and control require a
narrowing of vision. The great advantage of such
tunnel vision is that it brings into sharp focus
certain limited aspects of an otherwise far more
complex and unwieldy reality. This very
simplification, in turn, makes the phenomenon at
the center of the field of vision more legible and
hence more susceptible to careful measurement
and calculation….making possible a high degree of
schematic knowledge, control, and manipulation."
"Certain forms of knowledge and control require a
narrowing of vision. The great advantage of such
tunnel vision is that it brings into sharp focus
certain limited aspects of an otherwise far more
complex and unwieldy reality. This very
simplification, in turn, makes the phenomenon at
the center of the field of vision more legible and
hence more susceptible to careful measurement
and calculation….making possible a high degree of
schematic knowledge, control, and manipulation."
There is Great Power in Focusing on One Problem at a Time
There is Great Power in Focusing on One Problem at a Time
-- James Scott-- James Scott
0
1,000
2,000
3,000
4,000
5,000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Num
ber o
f Cig
aret
tes
Even the Greatest Gains are FragileEven the Greatest Gains are Fragile
Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.
“No improvements at all had been
made...open cesspools are still to
be seen...we have all the materials
for a fresh epidemic...the water-
butts were in deep cellars, close to
the undrained cesspool...The
overcrowding appears to increase."
“No improvements at all had been
made...open cesspools are still to
be seen...we have all the materials
for a fresh epidemic...the water-
butts were in deep cellars, close to
the undrained cesspool...The
overcrowding appears to increase."
Broad Street, One Year LaterBroad Street, One Year Later
SpecializationA Proven Problem Solving Approach
SpecializationA Proven Problem Solving Approach
Identify disease
Determine causes
Develop and test interventions
Implement programs and policies
Identify disease
Determine causes
Develop and test interventions
Implement programs and policies
Repeat steps 1-4, as necessary!Repeat steps 1-4, as necessary!
Side Effects of SpecializationSide Effects of SpecializationConfusion, inefficiency, organizational disarray
Competition for shared resources
Attention to “local” causes, near in time and space
Neglected feedback (+ and -)
Confounded evaluations
Coercive power dynamics
Priority on a single value, implicitly or explicitly devaluing others
Limited mandate to address context (living conditions) or infrastructure (public strength)
Disappointing track record, especially with regard to inequalities
Confusion, inefficiency, organizational disarray
Competition for shared resources
Attention to “local” causes, near in time and space
Neglected feedback (+ and -)
Confounded evaluations
Coercive power dynamics
Priority on a single value, implicitly or explicitly devaluing others
Limited mandate to address context (living conditions) or infrastructure (public strength)
Disappointing track record, especially with regard to inequalities
A
C
BD
E
A B C D EIssue Organizations
Neighborhood
Dangers of Getting Too SpecificDangers of Getting Too Specific
Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.
Conventional problem solving proliferates problems
Opens a self-reinforcing niche for professional problem solvers
Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)
Conventional problem solving proliferates problems
Opens a self-reinforcing niche for professional problem solvers
Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)
Examples of Nonviolent ActionExamples of Nonviolent Action
Albert Einstein Institution. Applications of nonvilolent action. Albert Einstein Institution, 2001.
Powers RS, Vogele WB, Kruegler C, McCarthy RM. Protest, power, and change: an encyclopedia of nonviolent action from ACT-UP to women's suffrage. New York: Garland Pub., 1997.
Dismantling dictatorships
Blocking coups d’état
Defending against foreign invasions and occupations
Providing alternatives to violence in extreme ethnic conflicts
Challenging unjust social and economic systems
Developing, preserving and extending democratic practices, human rights, civil liberties, and freedom of religion
Resisting genocide
Dismantling dictatorships
Blocking coups d’état
Defending against foreign invasions and occupations
Providing alternatives to violence in extreme ethnic conflicts
Challenging unjust social and economic systems
Developing, preserving and extending democratic practices, human rights, civil liberties, and freedom of religion
Resisting genocide
“A phenomenon that cuts across ethnic, cultural, religious,
geographic, socioeconomic and other demographic lines.”
“A phenomenon that cuts across ethnic, cultural, religious,
geographic, socioeconomic and other demographic lines.”
-- Albert Einstein Institution-- Albert Einstein Institution
Questioning the Character of Public Health WorkQuestioning the Character of Public Health WorkPUBLIC HEALTH WORK
InnovativeHealth
Ventures
SYSTEMS THINKING & MODELING (understanding change)
• What causes population health problems?
• How are efforts to protect the public’s health organized?
• How and when do health systems change (or resist change)?
PUBLIC HEALTH(setting direction)
What are health leaderstrying to accomplish?
SOCIAL NAVIGATION(governing movement)
Directing Change
Charting Progress
• Who does the work?• By what means?• According to whose values?
• How are conditions changing?• In which directions?
Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004.
Syndemic OrientationWorking Definition
Syndemic OrientationWorking Definition
A way of thinking about public health work that focuses on connections among
health-related problems, considers those connections when developing
health policies, and aligns with other avenues of social change to assure the
conditions in which all people can be healthy
A way of thinking about public health work that focuses on connections among
health-related problems, considers those connections when developing
health policies, and aligns with other avenues of social change to assure the
conditions in which all people can be healthy
Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense
Incorporates 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.
Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense
Incorporates 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.
Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation
System Dynamics
SocialNavigation
POLICYDEVELOPMENT
ASSESSMENT
ASSURANCE
NetworkAnalysis
CategoricalOrientationSyndemic
Orientation
“Solutions” CanCreate New Problems
“Solutions” CanCreate New Problems
Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904.
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
Many Systems Exhibit Policy ResistanceMany Systems Exhibit Policy Resistance
Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35.
Pear R. Health spending rises to record 15% of economy. The New York Times 2004 January 9.
Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.
“At least six times since the
Depression, the United States has
tried and failed to enact a national
health insurance program.”
“At least six times since the
Depression, the United States has
tried and failed to enact a national
health insurance program.”
-- Lee & Paxman-- Lee & Paxman
“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”
“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”
-- Meadows, Richardson, Bruckman-- Meadows, Richardson, Bruckman
Flaws in Previous Attempts at Health Reform in AmericaFlaws in Previous Attempts at Health Reform in America
Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.
Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at <http://www.cpn.org/topics/health/healthquestion.html>.
Piecemeal approaches
Comprehensive strategies that are opposed by special interests
Assumption that healthcare dynamics are separate from other areas of public concern
Conventional analytic methods make it difficult to
Observe the health system as a large, dynamic enterprise
Craft high-leverage strategies that can overcome policy resistance
Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be crafted)
Piecemeal approaches
Comprehensive strategies that are opposed by special interests
Assumption that healthcare dynamics are separate from other areas of public concern
Conventional analytic methods make it difficult to
Observe the health system as a large, dynamic enterprise
Craft high-leverage strategies that can overcome policy resistance
Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be crafted)
Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521.
How Many Triangles Do You See?How Many Triangles Do You See?
Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf
Boundary CritiqueBoundary Critique
Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf
Boundary CritiqueBoundary Critique
“You Can Argue with Einstein”“You Can Argue with Einstein”
Yankelovich D. Coming to public judgment: making democracy work in a complex world. 1st ed Syracuse, NY: Syracuse University Press, 1991. p. 220.Yankelovich D. Coming to public judgment: making democracy work in a complex world. 1st ed Syracuse, NY: Syracuse University Press, 1991. p. 220.
“For certain purposes, public judgment should
carry more weight than expert opinion – and not
simply because the majority may have more
political power than the individual expert but
because the public’s claim to know is actually
stronger than the experts’...the judgment of the
general public can, under some conditions, be equal
or superior in quality to the judgment of experts and
elites who possess far more information, education,
and ability to articulate their views.”
“For certain purposes, public judgment should
carry more weight than expert opinion – and not
simply because the majority may have more
political power than the individual expert but
because the public’s claim to know is actually
stronger than the experts’...the judgment of the
general public can, under some conditions, be equal
or superior in quality to the judgment of experts and
elites who possess far more information, education,
and ability to articulate their views.”
-- Daniel Yankelovich-- Daniel Yankelovich
Misleading Framing AssumptionsMisleading Framing Assumptions
Focus on the events
Everything that happens must have a cause
That cause must be close in time and space
Instantaneous impacts
Causality runs one-way
Independence
Impacts are linear and constant
Stepwise progress will lead to system-wide improvement
Focus on the events
Everything that happens must have a cause
That cause must be close in time and space
Instantaneous impacts
Causality runs one-way
Independence
Impacts are linear and constant
Stepwise progress will lead to system-wide improvement
Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.
These assumptions overlook non-local forces of change, such as feedback and delay
These assumptions overlook non-local forces of change, such as feedback and delay
What causes the behaviors we observe?What causes the behaviors we observe?
System-as-CauseSystem-as-Cause
“When we attribute behavior to
people rather than system structure
the focus of management becomes
scapegoating and blame rather than
the design of organizations in which
ordinary people can achieve
extraordinary results.”
“When we attribute behavior to
people rather than system structure
the focus of management becomes
scapegoating and blame rather than
the design of organizations in which
ordinary people can achieve
extraordinary results.”
-- John Sterman-- John Sterman
Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.
“The tendency to blame other people instead of the system is so strong
that psychologists call it the fundamental attribution error.”
“The tendency to blame other people instead of the system is so strong
that psychologists call it the fundamental attribution error.”
Beyond ScapegoatingBeyond Scapegoating
A Very Particular DistanceA Very Particular Distance
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.
“The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned
with the action of a single individual, but not so far away
as to be ignorant of the internal pressures in the system.”
-- George Richardson
“The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned
with the action of a single individual, but not so far away
as to be ignorant of the internal pressures in the system.”
-- George Richardson
“A symbolic instrument made of a number of methods and techniques
borrowed from very different disciplines…The macroscope
filters details and amplifies that which links things together. It is not used to make things larger or smaller but to observe what is at once too great, too slow, and too
complex for our eyes.”
“A symbolic instrument made of a number of methods and techniques
borrowed from very different disciplines…The macroscope
filters details and amplifies that which links things together. It is not used to make things larger or smaller but to observe what is at once too great, too slow, and too
complex for our eyes.”
Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html
-- Joèel de Rosnay-- Joèel de Rosnay
Looking Through the MacroscopeLooking Through the Macroscope
What processes or phenomena might
we need a macroscope to see?
What processes or phenomena might
we need a macroscope to see?
Time Series ModelsDescribe trends
Multivariate Stat Models
Identify historical trend drivers and correlates
Patterns
Structure
Events
Increasing:
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights
Increasing:
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights
Dynamic Models
Anticipate future trends, and find policies that maximize chances
of a desirable path
Tools for Policy AnalysisTools for Policy Analysis
Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
TargetedProtection
Society's HealthResponse
Demand forresponse
PublicWork
SaferHealthierPeople Becoming
vulnerable
Becoming saferand healthier
VulnerablePeople Becoming
afflicted
Afflictedwithout
Complications Developingcomplications
Afflicted withComplications
Dying fromcomplications
Health System DynamicsHealth System Dynamics
Adverse LivingConditions
GeneralProtection
Understanding Health as Public WorkUnderstanding Health as Public Work
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
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
World of Providing…
• Health Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access
Medical and Public Health Policy
MANAGEMENT OFRISKS AND DISEASES
World of Transforming…
• Deprivation• Dependency• Violence• Discrimination• Environmental decay• Stress• Insecurity
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
Becoming safer
and healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
Demand forresponse
GeneralProtection
TargetedProtection
PrimaryPrevention
SecondaryPrevention
TertiaryPrevention
PublicWork
Balancing Two Areas of EmphasisBalancing Two Areas of Emphasis
Testing Dynamic HypothesesTesting Dynamic Hypotheses
-- How can we learn about the consequences of actions in a system of this kind?-- Could the behavior of this system be analyzed using conventional epidemoiological methods (e.g., logistic or multi-level regression)?
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
Learning In and About Dynamic SystemsLearning In and About Dynamic Systems
Benefits of Simulation/Game-based Learning
Formal means of evaluating options
Experimental control of conditions
Compressed time
Complete, undistorted results
Actions can be stopped or reversed
Visceral engagement and learning
Tests for extreme conditions
Early warning of unintended effects
Opportunity to assemble stronger support
Benefits of Simulation/Game-based Learning
Formal means of evaluating options
Experimental control of conditions
Compressed time
Complete, undistorted results
Actions can be stopped or reversed
Visceral engagement and learning
Tests for extreme conditions
Early warning of unintended effects
Opportunity to assemble stronger support
Complexity Hinders
Generation of evidence (by eroding the conditions for experimentation)
Learning from evidence (by demanding new heuristics for interpretation)
Acting upon evidence (by including the behaviors of other powerful actors)
Complexity Hinders
Generation of evidence (by eroding the conditions for experimentation)
Learning from evidence (by demanding new heuristics for interpretation)
Acting upon evidence (by including the behaviors of other powerful actors)
Sterman JD. Learning from evidence in a complex world. AJPH 2006;96(3):505-514.
Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000.
“The complexity of our models vastly exceeds our ability to understand their implications without simulation."
-- John Sterman
“The complexity of our models vastly exceeds our ability to understand their implications without simulation."
-- John Sterman
Transforming the Future of Diabetes…Transforming the Future of Diabetes…
"Every new insight into Type 2 diabetes...
makes clear that it can be avoided--and that
the earlier you intervene the better. The real
question is whether we as a society are up to
the challenge...Comprehensive prevention
programs aren't cheap, but the cost of doing
nothing is far greater..."
Gorman C. Why so many of us are getting diabetes: never have doctors known so much about how to prevent or control this disease, yet the epidemic keeps on raging. how you can protect yourself. Time 2003 December 8. Accessed at http://www.time.com/time/covers/1101031208/story.html.
…in an Era of Epidemic Obesity
Re-Directing the Course of ChangeQuestions from System Modeling and Social NavigationRe-Directing the Course of ChangeQuestions from System Modeling and Social Navigation
20202010
Prevalence of Diagnosed Diabetes, US
0
5
10
15
1980 1985 1990 1995 2000
Mill
ion
peop
le
Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.
How?
Why?
Where?
Who?
Simulations for Learning in Dynamic SystemsDiabetes Dynamics in an Era of Epidemic Obesity
Simulations for Learning in Dynamic SystemsDiabetes Dynamics in an Era of Epidemic Obesity
Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.
Behavior Over Time (Experiments)Behavior Over Time (Experiments)Deaths per Population
0.0035
0.003
0.0025
0.002
0.0015
1980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Blue: Base run; Red: Clinical mgmt up from 66% to 90%;Green: Caloric intake down 4% (99 Kcal/day);Black: Clin mgmt up to 80% & Intake down 2.5% (62 Kcal/day)
Base
Downstream
Upstream
Mixed
Dynamic Hypothesis (Structure)Dynamic Hypothesis (Structure)
Setting Realistic ExpectationsHP 2010 Diabetes Objectives
Setting Realistic ExpectationsHP 2010 Diabetes Objectives
BaselineHP 2010 Target
Percent Change
Reduce Diabetes–related Deaths Among Diagnosed
(5-6)
8.8 per 1,000
7.8 -11%
Increase Diabetes Diagnosis (5-4)
68% 80% +18%
Reduce New Cases of Diabetes
(5-2)
3.5per 1,000
2.5 -29%
Reduce Prevalence of Diagnosed Diabetes
(5-3)
40 per 1,000
25 -38%
U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm
20
30
40
50
60
70
1980 1985 1990 1995 2000 2005 2010
Pe
op
le w
ith
dia
gn
ose
d d
iab
ete
s p
er
1,0
00
Reported Simulated
Status Quo
Meet Detection Objective (5-4)
Meet Onset Objective (5-2)
HP 2010 Objective (5-3)
HP 2000 Objective
History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results
History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results
A
B
C
D
E
F
G
H
I
The Simple Physics of DiabetesThe Simple Physics of Diabetes
It is impossible for any policy to reduce prevalence
38% by 2010!
People withUndiagnosed
Diabetes
People withDiagnosedDiabetes Dying from Diabetes
Complications
DiagnosedOnset
InitialOnset
People withNormal
GlycemicLevels
As would stepped-up detection effort
Reduced death wouldadd further to prevalence
With a diagnosed onset flow of
1.1 mill/yr
And a death flow of 0.5 mill/yr
(4%/yr rate)
The targeted 29% reduction in diagnosed onset can only
slow the growth in prevalence
“Simulation is a third way of doing science. Like deduction, it
starts with a set of explicit assumptions. But unlike deduction,
it does not prove theorems. Instead, a simulation generates
data that can be analyzed inductively. Unlike typical induction,
however, the simulated data comes from a rigorously specified
set of rules rather than direct measurement of the real world.
While induction can be used to find patterns in data, and
deduction can be used to find consequences of assumptions,
simulation modeling can be used as an aid to intuition.”
“Simulation is a third way of doing science. Like deduction, it
starts with a set of explicit assumptions. But unlike deduction,
it does not prove theorems. Instead, a simulation generates
data that can be analyzed inductively. Unlike typical induction,
however, the simulated data comes from a rigorously specified
set of rules rather than direct measurement of the real world.
While induction can be used to find patterns in data, and
deduction can be used to find consequences of assumptions,
simulation modeling can be used as an aid to intuition.”
-- Robert Axelrod-- Robert Axelrod
Axelrod R. Advancing the art of simulation in the social sciences. In: Conte R, Hegselmann R, Terna P, editors. Simulating Social Phenomena. New York, NY: Springer; 1997. p. 21-40. <http://www.pscs.umich.edu/pub/papers/AdvancingArtofSim.pdf>.
A Third Branch of ScienceA Third Branch of Science
Syndemic Orientation
Enlarging the Scope of Public Health WorkEnlarging the Scope of Public Health Work“Public health imagination involves using science to expand the
boundaries of what is possible.”
-- Michael Resnick
“Public health imagination involves using science to expand the boundaries of what is possible.”
-- Michael Resnick
EpidemicOrientation
People inPlaces
EcologicalThinking
Governing Dynamics
Ca
us
al
Ma
pp
ing
Plausible Futures
DynamicModeling
Navigational Freedoms
De
mo
cra
tic
Pu
bli
c W
ork
“We are as confused as ever, but on a higher
level and about more important things.”
“We are as confused as ever, but on a higher
level and about more important things.”
Humor Consultants, Inc.Humor Consultants, Inc.
To Sum UpTo Sum Up
For Additional Informationhttp://www.cdc.gov/syndemics