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Force Health Protection Under a Syndemic Orientation From Force Health Protection, To Forces for Protecting Health

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Title: Force Health Protection Under a Syndemic Orientation From Force Health Protection, To Forces for Protecting Health


1
Force Health Protection Under a Syndemic
Orientation From Force Health Protection, To
Forces for Protecting Health

Bobby Milstein 7th Annual Force Health
Protection Conference Albuquerque, NMAugust 10,
2004
2
Paradox of Protecting Health in an Unhealthy
Enterprise
For most people peace is not the highest value.
People, groups, and governments will not renounce
violence when that is seen to mean becoming
powerless and helpless in a conflict in which
their basic beliefs and the nature of their
society are, or are believed to be, under attack.
-- Gene Sharp
Sharp G. There are realistic alternatives. Boston
Mass Albert Einstein Institution, 2003.
http//65.109.42.80/organizations/org/TARA.pdf.
3
Science, 256, (12 June 1992) pp. 1520-1521
4
Preparing for Inevitable Conflict
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.
5
Joining Fields of Inquiry
InnovativeHealth Ventures
6
A Glimpse Into 2020
  • Rising Into Top 15
  • War
  • HIV
  • Violence
  • Self-inflicted injury
  • Cancer of the trachea, bronchus, and lung
  • Falling Below Top 15
  • Measles
  • Malaria
  • Falls
  • Anemia
  • Malnutrition

Murray CJL, Lopez AD. The global burden of
disease summary. Cambridge, MA Harvard
University Press, 1996.
7
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)

8
What does it mean to organize science and society
around the goal of assuring healthful conditions?
9
We are redefining CDC as the nations
health-protection agency.
-- Julie Gerberding
Time 100 the people who shape our world. Time
Magazine 2004 April 26.
10
Hygeia and Panacea
In no single thing do men approach the Gods more
nearly, than in the giving of safety to
mankind. Cicero
11
Exploring the Potential of a Syndemic Orientation
  • A study of innovations in health planning and
    evaluation
  • Member network includes
  • 244 individuals
  • 175 organizations
  • 11 countries

Centers for Disease Control and Prevention.
Spotlight on syndemics. Syndemics Prevention
Network, 2001. Available at lthttp//www.cdc.gov/sy
ndemicsgt.
12
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. AIDS and the health crisis of the US urban
poor The perspective of critical medical
anthropology. Social Science and Medicine
199439(7) 931-948. Singer M. A dose of drugs, a
touch of violence, a case of AIDS
Conceptualizing the SAVA syndemic. Free Inquiry
in Creative Sociology 199624(2) 99-110. Singer
M, Clair S. Syndemics and public health
reconceptualizing disease in bio-social context.
Medical Anthropology Quarterly 200317(4)423-441.

13
Focusing on Relationships
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
  • character and composition of the health response
    system

Health
Powerto Act
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
14
Moving Toward a Complementary Science of
Relationships
  • 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.
15
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."
-- Judith Summers
Summers J. Soho a history of London's most
colourful neighborhood. Bloomsbury, London, 1989.
p. 117.
16
Core Public Health Functions Under a Syndemic
Orientation
ASSESSMENT
SocialNavigation
NetworkAnalysis
CategoricalOrientation
SyndemicOrientation
System Dynamics
POLICYDEVELOPMENT
ASSURANCE
17
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. Meadows DH, Richardson J, Bruckmann
G. Groping in the dark the first decade of
global modelling. New York, NY Wiley, 1982.
18
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.
19
Looking Through the Macroscope
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.
-- Joèel de Rosnay
Rosnay Jd. The macroscope a book on the systems
approach. Principia Cybernetica, 1997.
lthttp//pespmc1.vub.ac.be/MACRBOOK.html
20
The Health System Exhibits Many of Our Toughest
Challenges
  • Dynamic complexityCause and effect are distant
    in time and space
  • Social complexityDiverse stakeholders with
    different agendas and worldviews
  • Adaptive complexitySolutions from the past may
    no longer be as effective

Adapted from Senge PM. Creating desired futures
in a global society. Reflections 20035(1)1-12.
21
Blood Lead Levels in the U.S. Population 19761999
22
Adult Per Capita Cigarette Consumption and Major
Smoking-and-Health EventsUnited States, 1900-1998

1st Surgeon Generals Report
Broadcast Ad Ban
Federal Cigarette Tax Doubles
End of WW II
Nonsmokers Rights Movement Begins
1st Smoking- Cancer Concern
Great Depression
Source USDA 1986 Surgeon General's Report
23
Actual and Expected Death Rates for Coronary
Heart Disease, 19501998
700
Rate if trend continued
600
500
Peak Rate
400
Age-adjusted Death Rate per 100,000 Population
300
200
Actual Rate
100
50
1950
1960
1970
1980
1990
1995
1955
1965
1975
1985
Year
Marks JS. The burden of chronic disease and the
future of public health. CDC Information Sharing
Meeting. Atlanta, GA National Center for Chronic
Disease Prevention and Health Promotion 2003.
24
Even the Greatest Gains are Fragile

25
Solutions Can Also Create 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.
26
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

Population
27
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.
28
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.
29
Examples of Nonviolent Action
  • Dismantling dictatorships
  • Blocking coups détat
  • 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.
-- Albert Einstein Institution
Albert Einstein Institution. Applications of
nonvilolent action. Albert Einstein Institution,
2001. http//www.aeinstein.org/. 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.
30
SpecializationA Proven Problem Solving Approach
  • Identify disease
  • Determine causes
  • Develop and test interventions
  • Implement programs and policies
  • Repeat steps 1-4, as necessary!

31
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

32
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.
33
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.
34
Misleading Framing Assumptions
  • Focus on the events
  • Everything that happens must have a cause, and
    that cause must be close in time and space
  • Instantaneous impacts
  • Causality runs one-way
  • Independence
  • Impacts are linear and constant

Richmond B, Peterson S, High Performance Systems
Inc. An introduction to systems thinking. Hanover
NH High Performance Systems, 1997.
35
Basic Problem Solving Orientations
Event Oriented View
Sterman J. Business dynamics systems thinking
and modeling for a complex world. Boston, MA
Irwin McGraw-Hill, 2000.
36
Basic Problem Solving Orientations
Feedback View
Sterman J. Business dynamics systems thinking
and modeling for a complex world. Boston, MA
Irwin McGraw-Hill, 2000.
37
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 responses (syndemic)

38
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.
39
System-as-Cause
40
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.
41
Health Protection as a System
From Milstein B, Homer J. The dynamics of
upstream and downstream why is so hard for the
health system to work upstream, and what can be
done about it? CDC Futures Health Systems
Workgroup Atlanta, GA 2003.
42
Assuring Healthful Conditions in War and the
Preparation for War
  • Adverse Effects on
  • People
  • Environment
  • Civic infrastructure
  • Human rights

Health Effects
  • Combatants
  • Noncombatants

Levy BS, Sidel VW. War and public health. Updated
ed. Washington DC American Public Health
Association, 2000.
43
Declining Deaths Among Combatants
Garfield RM, Neugut AI. The human consequences of
war. In Barry S. Levy VWS, editor. War and
public health. Updated ed. Washington DC
American Public Health Association 2000. p.
27-38.
44
Increasing Deaths Among Noncombatants
Garfield RM, Neugut AI. The human consequences of
war. In Barry S. Levy VWS, editor. War and
public health. Updated ed. Washington DC
American Public Health Association 2000. p.
27-38.
45
Rethinking the Paradox
For most people peace is not the highest value.
People, groups, and governments will not renounce
violence when that is seen to mean becoming
powerless and helpless in a conflict in which
their basic beliefs and the nature of their
society are, or are believed to be, under attack.
-- Gene Sharp
Sharp G. There are realistic alternatives. Boston
Mass Albert Einstein Institution, 2003.
http//65.109.42.80/organizations/org/TARA.pdf.
46
Methods of Nonviolent Action
Nonviolent action has nothing to do with
passivity, submissiveness, and cowardice just as
in violent conflict, these must first be rejected
and overcome. -- Gene Sharp
  • Acts of omission (N61 types)
  • -- Strikes, boycotts, civil disobedience
  • Acts of commission (N137 types)
  • -- Blockade, sabotage, counterfeiting
  • Combinations of both

Sharp G. There are realistic alternatives. Boston
Mass Albert Einstein Institution, 2003.
http//65.109.42.80/organizations/org/TARA.pdf. Sh
arp G. Correcting common misconceptations about
nonviolent action. Albert Einstein Institution,
1973. Accessed May 24, 2004 at lthttp//65.109.42.8
0/organizations/org/misconceptions.pdfgt.
47
Prospects for Wielding Power through Nonviolent
Action
The strength of even dictatorships is dependent
on sources of power in the society, which in turn
depend on the cooperation of a multitude of
institutions and peoplecooperation which may or
may not continue.
-- Gene Sharp
It is not about making a point, its about taking
power.
-- Ackerman DuVall
Sharp G. There are realistic alternatives. Boston
Mass Albert Einstein Institution, 2003.
http//65.109.42.80/organizations/org/TARA.pdf. Ac
kerman P, DuVall J. With weapons of the will how
to topple Saddam Hussein--nonviolently.
Sojourners Magazine 2002(September-October).
48
Who Will Be Our Model for Powerful Action in
Conflict?
Achilles
Ashoka
49
Ashokas Strategy
  • Security through powerful nonviolent action
  • Education
  • Transportation (roads with shade trees)
  • Well-digging (clean water)
  • Hospitals (people and animals)
  • Religious tolerance

50
Primary Prevention for War?
"America was not on a road to survival before
Martin Luther King. Atlanta would not look like
the thriving metropolis that it is now. Atlanta
would probably look more like Beirut if history
had gone its normal course, the normal violent
American way."
-- Andrew Young
From Kearns K. In Remembrance of Martin. PBS
Video, 1999.
51
Preparation for Nonviolent Action
I made up my mind that I would not give in any
longer to legally-imposed racial segregation. --
Rosa Parks
  • Parks was not first to defy segregation law
  • Her action on December 1, 1955 was not done on a
    whim, but rather was part of a carefully planned
    NAACP legal strategy
  • Parks action was preceded by 12 years of
    preparation
  • Served as secretary of NAACP
  • Studied at Highlander Folk School

Academy of Achievement. Rosa Parks pioneer of
civil rights. Hall of Public Service Academy of
Achievement, 2003. lthttp//www.achievement.org/au
todoc/page/par0int-1gt. 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.
52
Expanding the Fraction Conflicts that Employ
Nonviolent Means
Nonviolent Action Preparation for Nonviolent
Action
We do not hold the vision of a world without
conflict. We do hold the vision of a world
without warand this inevitably requires an
alternative system for coping with conflict.
War Preparation for War
-- Adlai Stevenson
Levy BS, Sidel VW. War and public health. Updated
ed. Washington DC American Public Health
Association, 2000., p. 371.
53
Roles for Health Professionals
  • As military noncombatants
  • Document and analyze the full spectrum of health
    effects, including their dynamics
  • Develop a balanced portfolio of responses
  • Care for afflicted
  • Prevention for those at risk
  • Protection for those most vulnerable
  • Expand opportunities for nonviolent action
  • As citizens,..
  • Reject blame, question system structure
  • Insist on policies to
  • Reduce the causes of violence
  • Control weapons
  • Strengthen capacity to engage in nonviolent action

Levy BS, Sidel VW. Preventing war and its health
consequences roles of public health
professionals. In Barry S. Levy VWS, editor. War
and public health. Updated ed. Washington DC
American Public Health Association 2000. p.
388-393.
54
Some Attributes of a Syndemic View
  • Sees the health protection enterprise in larger,
    more dynamic terms
  • Shifts from an exclusively stepwise view of
    change to one that is also transformational
  • Expands prevention science by formalizing new
    kinds of principles and processes (e.g., causal
    feedback)
  • Acknowledges sources of dynamic complexity and
    relies on analytic methods that can capture its
    effects

55
For Additional Information http//www.cdc.gov/synd
emics
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