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

bmilstein@cdc.govhttp://www.cdc.gov/syndemics

Bobby Milstein

Syndemics Prevention NetworkCenters for Disease Control and Prevention

bmilstein@cdc.govhttp://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