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Syndemics and the Interface Between Public Health, Systems Science, and Social Navigation

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Title: Syndemics and the Interface Between Public Health, Systems Science, and Social Navigation


1
Syndemics and the Interface Between Public
Health, Systems Science, and Social Navigation
Bobby MilsteinSyndemics Prevention
NetworkCenters for Disease Control and
Preventionbmilstein_at_cdc.govhttp//www.cdc.gov/sy
ndemics
Bobby Milstein Mid-America Regional Public
Health Leadership Institute April 7,
2006 Indianapolis, IN
2
(No Transcript)
3
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?
4
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
5
Diseases of Disarray
  • 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.
19933(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 199283(5)326-8.
6
New Word for a Familiar Phenomenon
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
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 19923(1)222-34. Sin
ger 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 200317(4)423-441.

7
What was Singer doing? What are the implications
for public health work? What methodologies
support this perspective (scientifically,
politically, morally)? What effects do these ways
of thinking and acting have in the world?
8
What Does it Mean to Approach Public Health Work
from a Syndemic Orientation?
  • Ongoing study of innovations in public health
    work
  • Member network includes
  • 419 individuals
  • 280 organizations
  • 19 countries

Centers for Disease Control and Prevention.
Spotlight on syndemics. Syndemics Prevention
Network, 2001. lthttp//www.cdc.gov/syndemicsgt.
9
Starting 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

10
Plan 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

11
Epidemic
  • 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

12
Public Health Began as Public Work
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.
-- Gil Elliot
Elliot G. Twentieth century book of the dead. New
York, C. Scribner, 1972.
13
Syndemic
  • 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

Co-occurring
Confounding
Connecting
Synergism
Syndemic
Includes several forms of connection or
inter-connection such as synergy, intertwining,
intersecting, and overlapping
14
Changing (and Accumulating) Ideas in Causal
TheoryWhat accounts for poor population health?
  • Gods 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)

Richardson GP. Feedback thought in social science
and systems theory. Philadelphia, PA University
of Pennsylvania Press, 1991.
15
Seeing Syndemics
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)

16
Placing Health in a Wider Set of Relationships
A syndemic orientation is one of a few
approaches that includes within it our power to
respond
17
A Philosophy of Means
Social and political theory have neglected the
central question of means, and, therefore, the
problem of inevitable conflict.
-- Joan Bondurant
Bondurant JV. Conquest of violence the Gandhian
philosophy of conflict. New rev. ed. Princeton N
J Princeton University Press, 1988.
18
Toward a Complementary Science of Relationships
True innovation occurs when things are put
together for the first time that had been
separate. Arthur Koestler
  • 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.
19
Questioning the Character of Public Health Work
PUBLIC HEALTH WORK
InnovativeHealth Ventures
20
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
  • 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.

Milstein B. Syndemic. In Mathison S, editor.
Encyclopedia of Evaluation. Thousand Oaks, CA
Sage Publications 2004.
21
Core Public Health Functions Under a Syndemic
Orientation
ASSESSMENT
SocialNavigation
NetworkAnalysis
CategoricalOrientation
SyndemicOrientation
System Dynamics
POLICYDEVELOPMENT
ASSURANCE
22
Solutions CanCreate New Problems

Merton RK. The unanticipated consequences of
purposive social action. American Sociological
Review 19361936894-904. Forrester JW.
Counterintuitive behavior of social systems.
Technology Review 197173(3)53-68.
23
Many Systems Exhibit Policy Resistance
The tendency for interventions to be delayed,
diluted, or defeated by the response of the
system to the intervention itself.
-- Meadows, Richardson, Bruckman
At least six times since the Depression, the
United States has tried and failed to enact a
national health insurance program.
-- Lee Paxman
Lee P, Paxman D. Reinventing public health.
Annual Reviews of Public Health
1997181-35. 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.
24
Flaws in Previous Attempts at Health Reform in
America
  • 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 produced)

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 lthttp//www.cpn.org/topics/health/hea
lthquestion.htmlgt.
25
How Many Triangles Do You See?
Wickelgren I. How the brain 'sees' borders.
Science 1992256(5063)1520-1521.
26
Boundary Critique
Ulrich W. Reflective practice in the civil
society the contribution of critically systemic
thinking. Reflective Practice 20001(2)247-268.
http//www.geocities.com/csh_home/downloads/ulrich
_2000a.pdf
27
Misleading 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

These assumptions overlook non-local forces of
change, such as feedback and delay
Richmond B, Peterson S, High Performance Systems
Inc. An introduction to systems thinking. Hanover
NH High Performance Systems, 1997.
28
What causes the behaviors we observe?
29
System-as-Cause
30
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.
Beyond Scapegoating
-- John Sterman
The tendency to blame other people instead of
the system is so strong that psychologists call
it the fundamental attribution error.
Sterman J. System dynamics modeling tools for
learning in a complex world. California
Management Review 200143(4)8-25.
31
A Very Particular Distance
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
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.
32
Looking Through the Macroscope
A symbolic instrument made of a number of
methods and techniques borrowed from very
different disciplinesThe 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.
-- Joèel de Rosnay
Rosnay Jd. The macroscope a book on the systems
approach. Principia Cybernetica, 1997.
lthttp//pespmc1.vub.ac.be/MACRBOOK.html
33
What processes or phenomena in your work might we
need a macroscope to see?
34
Tools for Policy Analysis
35
Health System Dynamics
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.
36
Understanding Health as Public Work
Public Work
-
Society's Health
Response
Tertiary
General
Targeted
Primary
Secondary
Prevention
Protection
Protection
Prevention
Prevention
Demand for
response
Becoming safer
and healthier
-
Safer
Afflicted
Vulnerable
Afflicted with
Healthier
without
People
Complications
People
Developing
Complications
Becoming
Becoming
vulnerable
afflicted
complications
Dying from
complications
Adverse Living
Conditions
37
Balancing Two Areas of Emphasis
38
Testing 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)?
39
Learning In and About Dynamic Systems
The complexity of our models vastly exceeds our
ability to understand their implications without
simulation." -- John Sterman
  • 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)

Sterman JD. Learning from evidence in a complex
world. AJPH 200696(3)505-514. Sterman JD.
Business Dynamics Systems Thinking and Modeling
for a Complex World. Boston, MA Irwin
McGraw-Hill, 2000.
40
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.h
tml.
41
Re-Directing the Course of ChangeQuestions from
System Modeling and Social Navigation
Where?
How?
Why?
Who?
2020
2010
42
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 200696(3)488-494.
43
Setting Realistic ExpectationsHP 2010 Diabetes
Objectives
Baseline HP 2010 Target Percent Change
Reduce Diabetesrelated 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
44
History and Futures for Diabetes
PrevalenceReported Trends, HP Objectives, and
Simulation Results
Meet Detection Objective (5-4)
I
Status Quo
G
Meet Onset Objective (5-2)
H
F
D
C
HP 2000 Objective
HP 2010 Objective (5-3)
E
45
The Simple Physics of Diabetes
People with
Undiagnosed
Initial
Diabetes
Onset
With a diagnosed onset flow of 1.1 mill/yr
Diagnosed
Onset
People with
Diagnosed
Dying from Diabetes
Diabetes
Complications
It is impossible for any policy to reduce
prevalence38 by 2010!
And a death flow of 0.5 mill/yr (4/yr rate)
46
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.
A Third Branch of Science
-- 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.
lthttp//www.pscs.umich.edu/pub/papers/AdvancingArt
ofSim.pdfgt.
47
Enlarging the Scope of Public Health Work
Public health imagination involves using science
to expand the boundaries of what is
possible. -- Michael Resnick
EpidemicOrientation
48
To Sum Up
We are as confused as ever, but on a higher
level and about more important things.
Humor Consultants, Inc.
49
For Additional Information http//www.cdc.gov/synd
emics
50
Systems Archetype
Fixes That Fail
Kim DH. Systems archetypes at a glance.
Cambridge, MA Pegasus Communications, Inc., 1994.
51
In Public Health Vocabulary
Fixes That Fail

Kim DH. Systems archetypes at a glance.
Cambridge, MA Pegasus Communications, Inc., 1994.
52
Exclusions
Social
Disorientation
Conceptual
Political
Organizational
Together, these forces threaten increasing
powerlessness of public health work
53
There is Great Power in Focusing on One Problem
at a Time
"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."
-- James Scott
Scott JC. Seeing like a state how certain
schemes to improve the human condition have
failed. New Haven London Yale University
Press, 1999.
54
Even the Greatest Gains are Fragile

55
Broad Street, One Year Later
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."
Summers J. Soho a history of London's most
colourful neighborhood. Bloomsbury, London,
1989. p. 117.
56
SpecializationA Proven Problem Solving Approach
  • Identify disease
  • Determine causes
  • Develop and test interventions
  • Implement programs and policies
  • Repeat steps 1-4, as necessary!

57
Side Effects of Specialization
  • 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

Neighborhood
58
Dangers of Getting Too Specific
  • 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)

Krug EG, World Health Organization. World report
on violence and health. Geneva World Health
Organization, 2002.
59
Boundary Critique
Ulrich W. Reflective practice in the civil
society the contribution of critically systemic
thinking. Reflective Practice 20001(2)247-268.
http//www.geocities.com/csh_home/downloads/ulrich
_2000a.pdf
60
How have you observed public health work
changing? What is driving those
transformations? Where is the field headed?
61
Innovations in Public Health Work
Steps in Public Health Problem Solving Trends and Emerging Priorities
Define the problem Eliminate health disparities Preparedness Avoid activity limitation Promote life satisfaction Increase healthy days
Determine the cause Social determinants of health Built environment Adverse childhood experiences Genetics
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 Increasing health care access
And scores more.
62
A Field in Transition
  • 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, critical,
    practical)Concerned with creating and protecting
    values like health, dignity, security,
    satisfaction, justice, wealth, and freedom in
    both means and ends

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)
63
Serious Challenges for Planners and Evaluators
  • Locating categorical disease programs within a
    broader system of health protection
  • Constructing credible knowledge without
    comparison/control groups
  • Differentiating questions that focus on
    attribution versus contribution
  • Balancing trade-offs between short- and long-term
    effects
  • Avoiding the pitfalls of professonalism
  • Harnessing the power of citizen-led public work
  • Defining standards and values for judgment
  • Others

64
Placing Health in a Wider Set of Relationships
Model boundaries influence the recognition of
feedback and potential sources of environmental
instability. -- Jay Forrest
Forrest J. Evolution and behavior of system
structure eight perspectives for examining a
complex issue. 22nd International Conference of
the System Dynamics Society Oxford, England
2004.
65
Exploring a Syndemic Orientation
  • Study of innovations in public health work, with
    emphasis on transformations in concepts and
    methods
  • The word syndemic signals special concern for
    many kinds of relationships
  • mutually reinforcing health problems
  • health status and living conditions
  • synergy/fragmentation in the health response
    system
  • Phase 1 (2001-2003) identify innovations and
    dilemmas develop working definitions explore
    relevant concepts and methods
  • Phase 2 (2004-2005) articulate the foundations
    of a syndemic orientation work with leaders at
    the CDC and beyond to stimulate creativity,
    innovation, and reorient health protection
    ventures

Health
Public Strength
Conditions
A syndemic orientation clarifies the dynamic and
democratic character of public health work
Milstein B. Spotlight on syndemics. Centers for
Disease Control and Prevention, 2001.
lthttp//www.cdc.gov/syndemicsgt
66
How strong an influence do planned public health
actions have on shaping the conditions for health?
67
Public Health Goals Are Expandingand
Accumulating
The perfection of means and confusion of goals
characterizes our age. -- Albert Einstein
  • Prevent disease and injury (1850 -- present)
  • Promote health and development (1974 -- present)
  • Assure the conditions in which people can be
    healthy (1988 -- present)

68
What does it mean to organize science and society
around the goal of assuring healthful conditions?
69
Goals Have a Nested Structure
  • Disease Prevention
  • Prevent disease and injury
  • Health Promotion
  • Prolong length
  • Improve quality
  • Eliminate disparity
  • Enhance satisfaction
  • Public Health
  • Assure the conditions for health for all

70
Stepwise or Synergy?
The time has come to close the book on
infectious diseases. We have basically wiped
out the infection in the United States. --
Surgeon General William Stewart (1967)
Percent of Afflictions Under Control


1850
2000
2100
1950
Year
For subgroups of the public no afflictions
have been controlled equitably except for
smallpox
71
Solving Problems and Creating Value
"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 bothresolve 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."
-- Peter Senge
Senge PM. Creating desired futures in a global
society. Reflections 20035(1)1-12.
72
Steps in a Syndemic Approach
  • Identify place or population
  • Organize with residents/members to
  • Identify afflictions and their relationships
  • Examine living conditions and why they differ
  • Devise beneficial system-wide policies
  • Build power to act
  • Direct the course of social change to assure the
    conditions for health for all
  • Expand to other places/populations, as necessary

73
Formalizing an OrientationJoining Concepts and
Methods
Syndemic Orientation
Where are we going?
What links to what?
What influences what?
Directed Public Work
Connections
Leverage
Navigational View
Network View
Systems View
Directional Data
Proximity Data
Causal Data
Milstein B. Syndemic. In Mathison S, editor.
Encyclopedia of Evaluation. Thousand Oaks, CA
Sage Publications 2004.
74
Studying Stability
There is no sociology of balance which is
interested in the social problems of a stabilized
societyThere is no political science of
equilibrium capable of enlightening us on the
means of exercising the democratic choice in a
society where short-term material gain would
cease to be the criterion of political success.
-- Joèel deRosnay
Rosnay Jd. The macroscope a book on the systems
approach. Principia Cybernetica, 1997. Accessed
May 23, 2003 at lthttp//pespmc1.vub.ac.be/MACRBOOK
.htmlgt.
75
Seeking Syn-Solutions
If the health consequences of sprawl represent a
syndemica combination of synergistic epidemics
that contributes to the population burden of
diseasethen solutions may also operate
synergistically, ameliorating several health
problems.
-- Howard Frumkin
Frumkin H. Urban sprawl and public health. Public
Health Reports 2002117(3)201-17.
76
The Feedback Thought
When X and Y affect each other, one cannot study
the link between X and Y and, independently, the
link between Y and X and predict how the system
will behave. Only the study of the whole system
as a feedback system will lead to correct
results."
-- System Dynamics Society
System Dynamics Society. What is system dynamics?
System Dynamics Society, 2002. Accessed December
19, 2002 at lthttp//www.systemdynamics.org/gt. Rich
ardson GP. Feedback thought in social science and
systems theory. Philadelphia University of
Pennsylvania Press, 1991.
77
What happens if we shift from thinking about the
variable-as-cause to the system-as-cause?
Argyris C. Actionable knowledge design causality
in the service of consequential theory. Journal
of Applied Behavioral Science 199632(4)390-408.
Dent E. The interactional model an alternative
to the direct cause and effect construct for
mutually causal organizational phenomena.
Foundations of Science in press. Richmond B. The
"thinking" in systems thinking seven essential
skills. Waltham, MA Pegasus Communications, 2000.
78
Beyond the Probable Future
Most organizations plan around what is most
likely. In so doing they reinforce what is, even
though they want something very
different. -- Ciement Bezold
  • PossibleWhat may happen?
  • PlausibleWhat could happen?
  • ProbableWhat will likely happen?
  • PreferableWhat do we want to have happen?

Bezold C, Hancock T. An overview of the health
futures field. Geneva WHO Health Futures
Consultation 1983 July 19-23.
79
Core Public Health Functions Under a Syndemic
Orientation
80
Policy Development
The future is not to be predicted, but
created. -- Arthur C. Clarke
  • Explicit model building
  • Simulated experiments
  • What if
  • What futures are plausible?
  • Real world action and observation

81
Analysis Process for Developing Policy
Events
Patterns
Time
Adapted from Successful Systems, Inc.
82
Source Randers JR. Elements of the System
Dynamics Method. Cambridge Mass Productivity
Press, 1980. p. xx.
83
Seeing the Whole System
  • Benefits
  • Places value on health and protection
  • Defines operational objectives (and timeframes)
  • Distinguishes types of work
  • Identifies needed information
  • Articulates a research agenda
  • Highlights Threats From
  • Imbalanced efforts
  • Short-sighted efforts
  • Adverse living conditions
  • Insufficient public work
  • Organizational disarray
  • Pitfalls of professionalism

84
Two Policy Orientations
Healthy Public Policy Medical and Public Health Policy
Concerned chiefly with assuring healthful conditions Concerned chiefly with preventing and alleviating affliction
Relies heavily on multiple small-scale local solutions, with low technology Relies heavily on singular high technology solutions, widely applied
Expands to a broader synthesis, transcending sector boundaries Confines analyses to the health sector
Future oriented Present oriented
Questions the givens Accepts the givens
Adapted from Hancock T. Beyond health care from
public health policy to healthy public policy.
Can J Public Health 198576 Suppl 19-11. Light
DW. The rhetorics and realities of community
health care the limits of countervailing powers
to meet the health care needs of the twenty-first
century. Journal of Health Politics, Policy, and
Law 199722(1)105-45.
85
Effective Screening and Care Actually Increase
Diagnosed Prevalence
  • The combination of more detection and decreasing
    deaths leads to more people living with diagnosed
    diabetes

86
What Could We Have Been Thinking?
87
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
88
Limits of Logic Models
  • Logic models may look reasonable, but they cant
    answer
  • Where to direct effort?
  • When to act?
  • How much effort will it take?
  • Whats the expected benefit?
  • When to expect change?
  • What is the difference between various
    approaches?
  • Such questions can only be answered by
    experimenting, either through simulation or in
    the real-world

89
Dynamic 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

Forrester JW. Counterintuitive behavior of social
systems. Technology Review 197173(3)53-68.
90
Steps for Putting Maps in Motion
  • 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

91
Why Simulate Proposed Policies?
Even the best conceptual models can only be
tested and improved by relying on the learning
feedback through the real worldThis feedback is
very slow and often rendered ineffective by
dynamic complexity, time delays, inadequate and
ambiguous feedback, poor reasoning skills,
defensive reactions, and the costs of
experimentation. In these circumstances
simulation becomes the only reliable way to test
a hypothesis and evaluate the likely effects of
policies."
-- John Sterman
Sterman J. Business dynamics systems thinking
and modeling for a complex world. Boston, MA
Irwin McGraw-Hill, 2000.
92
Assurance
The path resounds to our footfall, but do we
have it in ourselves to change
direction? -- Peter Ustinov
  • Assure conditions that expand peoples freedoms
    to live healthfully and develop their creative
    potential
  • Powered by democratic public work, including that
    of citizen-professionals
  • Navigational perspective, guided by vision and
    values
  • Forward orientation
  • Adapts to constantly changing conditions
  • Breakdown means-end framing

93
Solving for Pattern
"A bad solution is bad because it acts
destructively upon the larger patterns in which
it is contained...because it is formed in
ignorance or disregard of them. A bad solution
solves for a single purpose or goal, such as
increased production. And it is typical of such
solutions that they achieve stupendous increase
in production at exorbitant biological and social
costsGood solutions recognize that they are part
of a larger whole. They solve more than one
problem and don't create new problems. A good
solution should not enrich one person by the
distress or impoverishment of another."
-- Wendell Berry
Berry W. Solving for pattern. In The Gift of
Good Land. San Francisco North Point 1981. p.
134-45.
94
The Syndemics Prevention Network
You think you understand two because you
understand one and one. But you must also
understand and. -- Sufi Saying
  • The word syndemic signals special concern for
    many kinds of relationships
  • mutually reinforcing health problems
  • health status and living conditions
  • synergy/fragmentation in the health response
    system
  • Learning within innovative ventures
  • Comprehensive Community InitiativesPhilanthropy
  • Legacy InitiativesState Tobacco Settlements
  • Efforts to Eliminate Health Disparities
    Government and Philanthropy
  • Responses to Unjust Conditions Broad-based
    Citizen Organizations

Health
Public Strength
Conditions
A syndemic orientation clarifies the dynamic and
democratic character of public health work
Milstein B. Spotlight on syndemics. Centers for
Disease Control and Prevention, 2001.
lthttp//www.cdc.gov/syndemicsgt
95
Seeing Syndemics
True innovation occurs when things are put
together for the first time that had been
separate. Arthur Koestler
  • 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)

96
Placing Health in a Wider Set of Relationships
A syndemic orientation is one of a few
approaches that includes within it our power to
respond
97
Working in a New Era
Todays world, characterized by tremendous
globalization, connectivity, and speed poses
entirely new challenges. We have to be better
prepared to respond to the multiple public health
challenges, including those resulting from an
aging population, global threats of disease and
terrorism, obesity, and epidemic threats of
chronic diseases.
-- Julie Gerberding
Centers for Disease Control and Prevention. CDC
announces new goals and organizational design.
Atlanta, GA May 13, 2004. lthttp//www.cdc.gov/od/
oc/media/pressrel/r040513.htmgt.
98
What is the largest living organism?
99
Not Everything Meets the EyeLargest Living
Organism
100
Background on the Syndemics Project
You think you understand two because you
understand one and one. But you must also
understand and. -- Sufi Saying
  • Studying innovations in public health work, with
    emphasis on transformations in concepts and
    methods
  • The word syndemic signals special concern for
    many kinds of relationships
  • mutually reinforcing health problems
  • health status and living conditions
  • synergy/fragmentation in the health response
    system
  • Phase 1 (2001-2003) identify innovations and
    dilemmas develop working definitions explore
    relevant concepts and methods
  • Phase 2 (2004-2006) articulate the foundations
    of a syndemic orientation work with leaders at
    the CDC and beyond to stimulate creativity,
    innovation, and reorient health protection
    ventures

Health
Public Strength
Conditions
A syndemic orientation clarifies the dynamic and
democratic character of public health work
Milstein B. Spotlight on syndemics. Centers for
Disease Control and Prevention, 2001.
lthttp//www.cdc.gov/syndemicsgt
101
But What is a Syndemic Orientation?
A way of thinking about public health work that
focuses on connections among health-related
problems, considers those connections when
developing health policies, and aligns with other
avenues of social change to assure the conditions
in which all people can be healthy.
Aspects of a syndemic orientation incorporate
twenty-first century systems science and
political sensibilities, but the underlying
concepts are not new. Still, the implications of
adhering to this orientation remain largely
unexplored.
Milstein B. Syndemic. In Mathison S, editor.
Encyclopedia of Evaluation. Thousand Oaks, CA
Sage Publications 2004.
102
Seeing Syndemics
True innovation occurs when things are put
together for the first time that had been
separate. Arthur Koestler
  • The word syndemic signals special concern for
    many kinds of relationships
  • mutually reinforcing health problems
  • health status and living conditions
  • synergy/fragmentation in the health response
    system
  • Learning within innovative ventures
  • Comprehensive Community InitiativesPhilanthropy
  • Legacy InitiativesState Tobacco Settlements
  • Efforts to Eliminate Health Disparities
    Government and Philanthropy
  • Responses to Unjust Conditions Broad-based
    Citizen Organizations

Health
Public Strength
Conditions
A syndemic orientation clarifies the dynamic and
democratic character of public health work
Milstein B. Spotlight on syndemics. Centers for
Disease Control and Prevention, 2001.
lthttp//www.cdc.gov/syndemicsgt
103
Toward a Complementary Science of Relationships
You think you understand two because you
understand one and one. But you must also
understand and. -- Sufi Saying
  • Efforts to Reduce Population Health
    ProblemsProblem, problem solver, response
  • Efforts to Organize a System that Protects
    Population 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.
104
Continues Movement Away From Single-Issue
Epidemiology
  • Community Health Centers (COPC)
  • Health Systems Agencies
  • Environmental Justice
  • Health Care For All
  • Healthy Cities/Healthy Communities
  • Social Inequalities
  • Turning Point
  • Performance Standards
  • Ecosystem Health
  • Others.

Sirianni C, Friedland L. Community health and
civic organizing. In Civic innovation in
America community empowerment, public policy,
and the movement for civic renewal. Berkeley
University of California Press 2001. p. 138-185.
Levins R, Lopez C. Toward an ecosocial view of
health. International Journal of Health Services
199929(2)261-93.
105
Simulations for Learning in Dynamic SystemsThe
Problem of Outside Assistance
Dynamic Hypothesis (Structure)
Behavior Over Time (Experiments)
Homer J, Milstein B. Optimal decision making in a
dynamic model of poor community health.
Proceedings of the 37th Hawaii International
Conference on System Science Big Island, Hawaii
January 5-8, 2004. Available at
lthttp//csdl.computer.org/comp/proceedings/hicss/2
004/2056/03/205630085a.pdfgt.
106
Iterative Steps in System Dynamics Simulation
Modeling
Identify a Persistent Problem Graph its
behavior over time
Convert the Map Into a Simulation ModelFormally
quantify the hypothesis using allavailable
evidence
Learn About Policy Consequences Test proposed
policies, searching for ones that best govern
change
Create a Dynamic Hypothesis Identify and map
the main causal forces that create the problem
Run Simulation ExperimentsCompare models
behavior to expectations and/or data to build
confidence in the model
Milstein B, Homer J. Background on system
dynamics simulation modeling, with a summary of
major public health studies. Atlanta, GA
Syndemics Prevention Network, Centers for Disease
Control and Prevention February 1, 2005.
107
Redirecting the Course of ChangeQuestions from
System Dynamics and Social Navigation
Where?
14 increase
Why?
How?
Who?
2005
2025
2050
Zack MM, Moriarty DG, Stroup DF, Ford ES, Mokdad
AH. Worsening trends in adult health-related
quality of life and self-rated healthUnited
States, 1993-2001. Public Health Reports
2004119(September-October)493-505.
108
Basic Problem Solving Orientations
Sterman J. Business dynamics systems thinking
and modeling for a complex world. Boston, MA
Irwin McGraw-Hill, 2000.
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