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Title: Navigating Health Futures Using the Concepts of Syndemics and System Science


1
Navigating Health Futures Using the Concepts of
Syndemics and System Science
Bobby Milstein Syndemics Prevention
NetworkCenters for Disease Control and
Prevention bmilstein_at_cdc.gov http//www.cdc.gov/sy
ndemics
Institute for Public HealthGeorgia State
University November 29, 2007
2
Seeing Syndemics
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 the alignment of concepts, methods,
    and moral orientations
  • 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 protection
    system (e.g., by issues, sectors, organizations,
    professionals and other citizens)

Citizen-ship
A syndemic orientation clarifies the dynamic and
democratic character of public health work
  • It is one of a few approaches that explicitly
    includes within it our power to respond, along
    with an understanding of its changing pressures,
    constraints, and consequences

Milstein B. Spotlight on syndemics. Centers for
Disease Control and Prevention, 2001.
lthttp//www.cdc.gov/syndemicsgt
3
Exploring the Dynamic and Democratic Characterof
Public Health Work
PUBLIC HEALTH WORK
InnovativeHealth Ventures
4
Changing (and Accumulating) Views of Population
HealthWhat Accounts for Poor Population Health?
  • Gods will
  • Humors, miasma, ether
  • Poor living conditions, immorality
  • Single disease, single cause
  • Single disease, multiple causes
  • Single cause, multiple diseases
  • Multiple causes, multiple diseases (but no
    feedback dynamics)
  • Dynamic feedback among afflictions, living
    conditions, and public strength

Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Atlanta, GA Centers for Disease Control and
Prevention, (forthcoming). Richardson GP.
Feedback thought in social science and systems
theory. Philadelphia, PA University of
Pennsylvania Press, 1991.
5
Epidemic
  • The term epidemic is an ancient word signifying a
    kind of relationship wherein something is put
    upon the people
  • Epidemiology first appeared just over a century
    ago (in 1873), in the title of J.P. Parkin's book
    "Epidemiology, or the Remote Cause of Epidemic
    Diseases
  • Ever since then, the conditions that cause health
    problems have increasingly become matters of
    public concern and public work

A representation of the cholera epidemic of the
nineteenth century.Source NIH
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. Martin PM,
Martin-Granel E. 2,500-year evolution of the term
epidemic. Emerging Infectious Diseases 2006.
Available from http//www.cdc.gov/ncidod/EID/vol1
2no06/05-1263.htm National Institutes of Health.
A Short History of the National Institutes of
Health. Bethesda, MD 2006. Available from
http//history.nih.gov/exhibits/history/ Parkin
J. Epidemiology or the remote cause of epidemic
diseases in the animal and the vegetable
creation. London J and A Churchill, 1873.
6
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 population health as 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
7
Boundary Critique
Creating a new theory is not like destroying an
old barn and erecting a skyscraper in its place.
It is rather like climbing a mountain, gaining
new and wider views, discovering unexpected
connections between our starting point and its
rich environment.
-- Albert Einstein
Ulrich W. Boundary critique. In Daellenbach HG,
Flood RL, editors. The Informed Student Guide to
Management Science. London Thomson 2002. p.
41-42. lthttp//www.geocities.com/csh_home/download
s/ulrich_2002a.pdfgt. Ulrich W. Reflective
practice in the civil society the contribution
of critically systemic thinking. Reflective
Practice 20001(2)247-268. http//www.geocities.c
om/csh_home/downloads/ulrich_2000a.pdf
8
The Weight of Boundary Judgments
Forrester JW. Counterintuitive behavior of social
systems. Technology Review 197173(3)53-68. Meado
ws DH. Leverage points places to intervene in a
system. Sustainability Institute, 1999.
Available at lthttp//www.sustainabilityinstitute.
org/pubs/Leverage_Points.pdfgt. Richardson GP.
Feedback thought in social science and systems
theory. Philadelphia, PA University of
Pennsylvania Press, 1991. Sterman JD. Business
dynamics systems thinking and modeling for a
complex world. Boston, MA Irwin McGraw-Hill,
2000.
9
Implications for Policy Planning and Evaluation
  • Insights from the Overview Effect
  • Maintain a particular analytic distance
  • Not too close to the details, but not too far as
    be insensitive to internal pressures
  • Potential to anticipate temporal patterns (e.g.,
    better before worse)
  • Structure determines behavior
  • Potential to avoid scapegoating or lionizing

Richardson GP. Feedback thought in social science
and systems theory. Philadelphia, PA University
of Pennsylvania Press, 1991. Richmond B. Systems
thinking critical thinking skills for the 1990s
and beyond. System Dynamics Review
19939(2)113-134. Available at
lthttp//www.clexchange.org/ftp/documents/whyk12sd/
Y_1993-05STCriticalThinking.pdfgt. White F. The
overview effect space exploration and human
evolution. 2nd ed. Reston VA American Institute
of Aeronautics and Astronautics, 1998.
10
Tools for Policy Planning Evaluation
Events
Time Series Models Describe trends
  • Increasing
  • Depth of causal theory
  • Robustness for longer-term projection
  • Value for developing policy insights
  • Degrees of uncertainty
  • Leverage for change

Multivariate Stat Models Identify historical
trend drivers and correlates
Patterns
Dynamic Simulation Models Anticipate new
trends, learn about policy consequences, and set
justifiable goals
Structure
11
Public Health Systems ScienceAddresses
Navigational Policy Questions
Where?
What?
17 increase
How?
Why?
Who?
Centers for Disease Control and Prevention.
Health-related quality of life prevalence data.
National Center for Chronic Disease Prevention
and Health Promotion, 2007. Accessed October 23,
2007 at lthttp//apps.nccd.cdc.gov/HRQOL/index.aspgt
. Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Atlanta, GA Centers for Disease Control and
Prevention Draft, 2007.
12
Broad Dynamics of the Health Protection
Enterprise
Prevalence of Vulnerability, Risk, or Disease
100
Values for Health Equity
Size of the Safer, Healthier Population
PotentialThreats
0
Time
To understand and govern health trajectories over
time, our concepts and methods for policy
analysis must encompass the basic features of
this dynamic and democratic system
13
John Snow Heroic Success or Cautionary Tale?
Galea S. Macrosocial determination of population
health the example of urbanization. NCEH/ATSDR
Director's Science Seminar Series Atlanta, GA
Centers for Disease Control and Prevention
February 7, 2007.
14
Broad Street, One Year Later
John Snow Heroic Success or Cautionary Tale?
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."
Centers for Disease Control and Prevention. 150th
anniversary of John Snow and the pump handle.
MMWR 200453(34)783. Available at
lthttp//www.cdc.gov/mmwr/preview/mmwrhtml/mm5334a1
.htmgt Summers J. Soho a history of London's most
colourful neighborhood. Bloomsbury, London,
1989. p. 117. Milstein B. Hygeia's constellation
navigating health futures in a dynamic and
democratic world. Atlanta, GA Centers for
Disease Control and Prevention Draft, 2007.
15
What Do These Observations Having in Common?
  • Low tar and low nicotine cigarettesLead to
    greater carcinogen intake
  • Fad dietsProduce diet failure and weight gain
  • Road building to ease congestion Attracts
    development, increases traffic, delays,
    pollution, and urban sprawl
  • Antibiotic pesticide useStimulate resistant
    strains
  • Air-conditioning useRaises neighborhood heat
  • Forest fire suppressionBuilds deadwood fueling
    larger, hotter, more dangerous fires
  • War on drugs Raises price and attracts supply
  • Suppressing dissent Inspires radicalization and
    extremism

Sterman JD. Learning from evidence in a complex
world. American Journal of Public Health
200696(3)505-514. Forrester JW.
Counterintuitive behavior of social systems.
Technology Review 197173(3)53-68.
16
Policy Resistance is
Defining Keywords
The tendency for interventions to be delayed,
diluted, or defeated by the response of the
system to the intervention itself.
-- Meadows, Richardson Bruckmann
Meadows DH, Richardson J, Bruckmann G. Groping in
the Dark The First Decade of Global Modelling.
Wiley New York, 1985.
17
Systems Archetype
Fixes that Fail
Fix
Characteristic Behavior Better before Worse
Kim DH. Systems archetypes at a glance.
Cambridge, MA Pegasus Communications, Inc., 1994.
18
Fixes that Fail in Public Health Vocabulary
The Risk of Targeted Interventions

Health
TargetedResponse
B
Problem
-

What issues tend to be excluded?
Exclusions

19
Some Categories of Exclusions
Social
Disorientation
Conceptual
Political
Organizational
Together, these forces may seriously undermine
the effectiveness of health protection policy
20
Seeking High-Leverage Policies
Give me a firm place to stand and I will move
the earth. -- Archimedes
Wall painting in the Stanzino delle Matematiche
in the Galleria degli Uffizi (Florence, Italy).
Painted by Giulio Parigi in the years 1599-1600.
Meadows DH. Leverage points places to intervene
in a system. Sustainability Institute, 1999.
Available at lthttp//www.sustainabilityinstitute.
org/pubs/Leverage_Points.pdfgt.
21
Learning In and About Dynamic Systems
Real World
  • Unknown structure
  • Dynamic complexity
  • Time delays
  • Impossible experiments

Virtual World
  • Known structure
  • Controlled experiments
  • Enhanced learning
  • Implementation
  • Game playing
  • Inconsistency
  • Short term
  • Selected
  • Missing
  • Delayed
  • Biased
  • Ambiguous

Information
Decisions
Feedback
  • Misperceptions
  • Unscientific
  • Biases
  • Defensiveness
  • Inability to infer dynamics from mental
    models

Sterman JD. Learning in and about complex
systems. System Dynamics Review
199410(2-3)291-330. Sterman JD. Business
dynamics systems thinking and modeling for a
complex world. Boston, MA Irwin McGraw-Hill,
2000.
22
Selected CDC Projects Featuring System Dynamics
Modeling (2001-2007)
The complexity of our mental models vastly
exceeds our ability to understand their
implications without simulation." -- John
Sterman
  • Grantmaking ScenariosTiming and sequence of
    outside assistance
  • Upstream-Downstream EffortBalancing disease
    treatment with prevention/protection
  • Healthcare ReformRelationships among cost,
    quality, equity, and health status
  • Chronic Illness DynamicsHealth and economic
    scenarios for downstream and upstream reforms
  • Health ProtectionHealth Equity Multiplayer game
    to govern health status, cost, and equity in the
    U.S.
  • Syndemics Mutually reinforcing afflictions
  • Diabetes In an era of rising obesity
  • ObesityLifecourse consequences of changes in
    caloric balance
  • Infant HealthFetal and infant morbidity/mortality
  • Heart Disease and StrokePreventing and managing
    multiple risks, in context

Sterman JD. Business Dynamics Systems Thinking
and Modeling for a Complex World. Boston, MA
Irwin McGraw-Hill, 2000. 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. lthttp//www2.cdc.gov
/syndemics/pdfs/SD_for_PH.pdfgt.
23
Neighborhood Transformation Game
Homer J, Milstein B. Optimal decision making in a
dynamic model of poor community health. 37th
Hawaii International Conference on System
Science Big Island, HI January 5-8, 2004.
lthttp//csdl.computer.org/comp/proceedings/hicss/2
004/2056/03/205630085a.pdf Homer J, Milstein B.
Syndemic simulation. Forio Business Simulations,
2003. lthttp//broadcast.forio.com/sims/syndemic200
3/gt.
24
Picture a Neighborhood Where
  • Conditions are not supportive of healthy living
  • People are either afflicted by or at risk for
    numerous mutually reinforcing health problems
  • Citizen leaders are making an effort to alleviate
    afflictions and improve living conditions, but
    their power is limited
  • More could be done through local, broad-based
    organizing and with effective assistance from
    outside allies (e.g., philanthropy, government)

How does public health work typically proceed in
such circumstances?
25
Your Mission
Assure the conditions in all which people can be
healthy
  • Improve health
  • Enhance living conditions
  • Build strength

26
DefinitionHealth
A state of complete physical, social and mental
well-being, and not merely the absence of disease
or infirmity.
-- World Health Organization
World Health Organization. Health promotion
glossary. World Health Organization, 1998.
Available at lthttp//www.who.int/hpr/docs/glossar
y.htmlgt.
Centers for Disease Control and Prevention.
Measuring healthy days population assessment of
health-related quality of life. Atlanta, GA U.S.
Department of Health and Human Services, 2000.
Available at http//www.cdc.gov/hrqol/monograph.h
tm
27
DefinitionLiving Conditions
Living conditions are the everyday environment
of people, where they live, play and work. These
living conditions are a product of social and
economic circumstances and the physical
environment all of which can impact upon health
and are largely outside of the immediate
control of the individual.
-- World Health Organization
World Health Organization. Health promotion
glossary. World Health Organization, 1998.
Available at lthttp//www.who.int/hpr/docs/glossar
y.htmlgt.
Hillemeier MM, Lynch J, Harper S, Casper M. Data
set directory of social determinants of health at
the local level. Atlanta, GA Division for Heart
Disease and Stroke Prevention, Centers for
Disease Control and Prevention May 12, 2006.
lthttp//www.cdc.gov/dhdsp/library/data_set_directo
ry/pdfs/data_set_directory.pdfgt.
28
DefinitionCapacity for Action
The ability of individuals and organizations
to apply their skills and resources in collective
efforts to address health priorities and meet
their respective health needs.
-- World Health Organization
World Health Organization. Health promotion
glossary. World Health Organization, 1998.
Available at lthttp//www.who.int/hpr/docs/glossar
y.htmlgt.
29
Planning Effective Strategies
  • Focus assistance on
  • Fighting affliction
  • Improving adverse living conditions
  • Building public strength
  • Game Setup
  • Allies commit to assist for a period of 12 years
  • Total budget is set, but you may decide every
    four years (at T0, T4, and T8) how to allocate
    among the three types
  • Stakeholders observe changes during the 12 years
    of assistance, and also during a post-assistance
    follow-up period of 8 years
  • Goal is to reduce the average affliction burden
    both during and after assistance (T4-T20),
    recognizing that adverse living conditions and
    public strength are closely linked to that goal
    and may undermine it if left unaddressed

30
What are Typical Investment Schemes?
31
Which Causal Forces Drive Neighborhood Change?
Under What Conditions Do Syndemics Emerge? How
Can they be Controlled?
Affliction
prevalence
burden
Public
strength
Adverse
living
conditions
Key Rectangle Stock/state variable Blue arrow
same-direction link Green arrow
opposite-direction link Circled B balancing
causal loop Circled R reinforcing causal loop
Adapted from Homer J, Milstein B. Optimal
decision making in a dynamic model of poor
community health. 37th Hawaii International
Conference on System Science Big Island, HI
January 5-8, 2004. Available at
lthttp//csdl.computer.org/comp/proceedings/hicss/2
004/2056/03/205630085a.pdfgt. Milstein B. Hygeia's
constellation navigating health futures in a
dynamic and democratic world. Atlanta, GA
Centers for Disease Control and Prevention
(forthcoming).
32
Moving from the Map to a Model
  • Initial conditions were set to represent a
    neighborhood that is relatively disadvantaged and
    divided, with significant afflictions, adverse
    living conditions, and low public strength
  • The model contains about two dozen parameters
    that may vary from case to case. These are
    constants describing
  • Neighborhood CharacteristicsBaseline rates of
    affliction incidence and recovery, baseline
    strength and living conditions, and linkages
    among these variables
  • Program CharacteristicsEffectiveness of programs
    (benefit per unit of program effort)
  • Assistance Characteristicscost-effectiveness of
    assistance (additional program effort per unit of
    outside assistance)
  • Sensitivity analyses tested a wide range of
    plausible settings to assess the importance of
    parameter uncertainties

Homer J, Milstein B. Optimal decision making in a
dynamic model of poor community health. 37th
Hawaii International Conference on System
Science Big Island, HI January 5-8, 2004.
Available at lthttp//csdl.computer.org/comp/proce
edings/hicss/2004/2056/03/205630085a.pdfgt. Homer
JB, Oliva R. Maps and models in system dynamics
a response to Coyle. System Dynamics Review
200117(4)347-355.
33
A Model Is
  • An inexact representation of the real thing

All models are wrong, some are useful. --
George Box
Sterman JD. All models are wrong reflections on
becoming a systems scientist. System Dynamics
Review 200218(4)501-531. Available at
lthttp//web.mit.edu/jsterman/www/All_Models.htmlgt
Sterman J. A sketpic's guide to computer models.
In Barney GO, editor. Managing a Nation the
Microcomputer Software Catalog. Boulder, CO
Westview Press 1991. p. 209-229.
lthttp//web.mit.edu/jsterman/www/Skeptic27s_Guide
.htmlgt
34
Simulating the Development of a SyndemicOnset
and Plausible Futures
Affliction Burden (Average Unhealthy Days per
person/month)
12
New Average 10.14 Even deeper disparity 49
4.3 days/month 51 15.7 days/month
10.5
What Other Futures are Plausible?
9
All Affliction Assistance
7.5
6
Disguising a skewed distribution 85 4.3
days/month 15 15.7 days/month
4.5
0
13.3
20
-6.7
0
6.7
-20
-13.3
Year
Growth
No Assist
All Afflict
Homer J, Milstein B. Optimal decision making in a
dynamic model of poor community health. 37th
Hawaii International Conference on System
Science Big Island, HI January 5-8, 2004.
Available at lthttp//csdl.computer.org/comp/proce
edings/hicss/2004/2056/03/205630085a.pdfgt.
35
Simulating Alternative Strategies
Step 1 Define Intervention Scenarios
Scenario Name Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to
Scenario Name Affliction Affliction Affliction Living Conditions Living Conditions Living Conditions Public Strength Public Strength Public Strength
Scenario Name T0 T4 T8 T0 T4 T8 T0 T4 T8
No Assist 0 0 0 0 0 0 0 0 0
All Afflict 1 1 1 0 0 0 0 0 0




Total must be 1.0
Step 2 Sketch the Consequences Over Time
Affliction Burden Average Unhealthy Days per
person/month (0-30)
Adverse Living Conditions Prevalence Fraction of
Living Conditions that Threaten Health (0-1)
Public Strength Power of Citizens to Act
Effectively (0-1)
0.4
0.3
0.2
0.1
0
0
4
8
12
16
20
Year
Draw multiple lines on the same graph by
labeling each
36
Simulating Alternative Strategies
Step 1 Define Intervention Scenarios
Scenario Name Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Fraction of Assistance to Average Affliction Burden (T4-T20) Improvement Over Baseline ()
Scenario Name Affliction Affliction Affliction Living Conditions Living Conditions Living Conditions Public Strength Public Strength Public Strength Average Affliction Burden (T4-T20) Improvement Over Baseline ()
Scenario Name T0 T4 T8 T0 T4 T8 T0 T4 T8 Average Affliction Burden (T4-T20) Improvement Over Baseline ()
No Assist 0 0 0 0 0 0 0 0 0 10.20 --
All Afflict 1 1 1 0 0 0 0 0 0 8.52 16.0



Total must be 1.0
Step 2 Sketch the Consequences Over Time
Affliction Burden Average Unhealthy Days per
person/month (0-30)
Adverse Living Conditions Prevalence Fraction of
Living Conditions that Threaten Health (0-1)
Public Strength Power of Citizens to Act
Effectively (0-1)
0.4
0.3
0.2
0.1
0
0
4
8
12
16
20
Year
Draw multiple lines on the same graph by
labeling each
37
Affliction Burden Under Basic SettingFour
Different Assistance Schemes
12
10
8
Unhealthy Days
6
4
0
2
4
6
8
10
12
14
16
18
20
Time (years)
Avg
affliction burden T4-T20
Affliction burden BasicOpt
8.1
Affliction burden BasicAF111
8.5
Affliction burden BasicLC111
8.8
8.3
Affliction burden BasicPS111
Homer J, Milstein B. Optimal decision making in a
dynamic model of poor community health. 37th
Hawaii International Conference on System
Science Big Island, HI January 5-8, 2004.
Available at lthttp//csdl.computer.org/comp/proce
edings/hicss/2004/2056/03/205630085a.pdfgt.
38
Understanding the Structural Basis for Observed
Results
  • Why invest early in building Public Strength?It
    magnifies the effectiveness of later Affliction
    assistance
  • Why no Living Conditions assistance? It
    detracts from Strength if done early (loop B3b),
    and its benefits are too slow if done later
  • Why the Rebound in Affliction after T12?Switch
    from Strength assistance to Affliction assistance
    allows Strength to erode, so that residents are
    weaker after assistance ends at T12 and cant
    maintain programs
  • The optimal scheme reflects evaluation period end
    at T20. A longer evaluation period would give
    more weight to the Affliction rebound, and could
    give Strength assistance greater prominence.
  • If eval end time is T21, T26, stay with
    Strength assist until T8
  • If eval end time is T27 or later, stay with
    Strength assist throughout

39
Gaming Enables Visceral Learning
  • Invest Early in Building Public Strength
  • The first priority of philanthropies and
    government, when working in areas that are weak
    and struggling against multiple afflictions,
    should be to assist in building public strength
    (enabling a greater degree of citizen-led public
    work), perhaps even before substantial assistance
    is provided for direct fighting of prevalent
    diseases
  • Problem-fighting programs may have perverse
    effects on public strength when the area
    residents and institutions are weak and divided
    to begin with
  • Beware the Side Effects of Outside Assistance
    Related to Living Conditions
  • Outside assistance aimed directly at improving
    living conditions may often be insufficiently
    cost-effective, due to time lags and side effects
    that weaken public strength, to warrant making
    such assistance a high priority in the absence of
    widespread citizen participation

40
Simulations for Learning in Dynamic Systems
Multi-stakeholder Dialogue
Morecroft JDW, Sterman J. Modeling for learning
organizations. Portland, OR Productivity Press,
2000. Sterman JD. Business dynamics systems
thinking and modeling for a complex world.
Boston, MA Irwin McGraw-Hill, 2000.
41
Expanding Public Health Science
Public health imagination involves using science
to expand the boundaries of what is
possible. -- Michael Resnick
EpidemicOrientation
42
For Further Information
  • CDC Syndemics Prevention Network
    http//www.cdc.gov/syndemics
  • NIH/CDC Symposia on System Science and
    Healthhttp//obssr.od.nih.gov/Content/Lecturesan
    dSeminars/Systems_Symposia_Series/SEMINARS.htm
  • Recommended Reading
  • AJPH theme issue on systems thinking and modeling
    (March, 2006)http//www.ajph.org/content/vol96/is
    sue3/
  • Sterman JD. Learning from evidence in a complex
    world. AJPH 200696(3)505-514.
  • Midgley G. Systemic intervention for public
    health. AJPH 200696(3)466-472.
  • Homer JB, Hirsch GB. System dynamics modeling for
    public health background and opportunities. AJPH
    200696(3)452-458.
  • Sterman JD. A skeptic's guide to computer models.
    In Barney GO, editor. Managing a Nation the
    Microcomputer Software Catalog. Boulder, CO
    Westview Press 1991. p. 209-229.
    http//web.mit.edu/jsterman/www/Skeptic27s_Guide.
    html
  • Meadows DH. Leverage points places to intervene
    in a system. Sustainability Institute, 1999.
    http//www.sustainabilityinstitute.org/pubs/Levera
    ge_Points.pdf
  • Meadows DH, Robinson JM. The electronic oracle
    computer models and social decisions. System
    Dynamics Review 200218(2)271-308.

43
One Observers View
Public health is probably the most successful
system of science and technology combined, as
well as social policy, that has ever been
devisedIt is, I think, a paradigmatic model for
how you do concerned, humane, directed science.
-- Richard Rhodes
How is it directed?
Rhodes R. Limiting human violence an emerging
scientific challenge. Sarewitz D, editor. Living
With the Genie Governing Science and Technology
in the 21st Century New York, NY Center for
Science, Policy, and Outcomes 2002.
44
A Navigational View of Public Health Work
Where we want to go?
How do we prepare to get there?
Where you do want to live?
Where do you want your children to live?
Thompson N. Reflections on voyaging and home.
Polynesian Voyaging Society, 2001. Accessed July
18 at lthttp//leahi.kcc.hawaii.edu/org/pvs/malama/
voyaginghome.htmlgt. Milstein B. Hygeia's
constellation navigating health futures in a
dynamic and democratic world. Atlanta, GA
Centers for Disease Control and Prevention
Draft, 2007.
45
A Navigational View of Public Health Work
"How do you know," I asked, "that in twenty years
those things that you consider special are still
going to be here?" At first they all raised their
hands but when they really digested the question
every single one of them put their hands down. In
the end, there was not a single hand up. No one
could answer that question. It was the most
uncomfortable moment of silence that I can
rememberThat was the defining moment for me. I
recognized that I have to participate in
answering that question otherwise I am not taking
responsibility for the place I love and the
people I love.
-- Nainoa Thompson
Thompson N. Reflections on voyaging and home.
Polynesian Voyaging Society, 2001. Accessed July
18 at lthttp//leahi.kcc.hawaii.edu/org/pvs/malama/
voyaginghome.htmlgt.
46
A Navigational View of Public Health Work
"How do you know," I asked, "that in twenty years
those things that you consider special are still
going to be here?" At first they all raised their
hands but when they really digested the question
every single one of them put their hands down. In
the end, there was not a single hand up. No one
could answer that question. It was the most
uncomfortable moment of silence that I can
rememberThat was the defining moment for me. I
recognized that I have to participate in
answering that question otherwise I am not taking
responsibility for the place I love and the
people I love.
-- Nainoa Thompson
Thompson N. Reflections on voyaging and home.
Polynesian Voyaging Society, 2001. Accessed July
18 at lthttp//leahi.kcc.hawaii.edu/org/pvs/malama/
voyaginghome.htmlgt.
47
Power Has to be Organized
Academics and pundits love to throw around the
term social capital and debate its nuances,
but most of them couldnt organize a block party.
-- Ed Chambers
Chambers ET, Cowan MA. Roots for radicals. New
York Continuum, 2003., p. 65.
48
Becoming a Professional Often Implies Standing
Outside of the Public
The challenge of involving the community is
especially difficult if one has been trained, as
I have been trained, to be an arrogant, elitist
prima donna. I am the expert, after all, and I
help people by sharing my expertise.
-- Len Syme
Innovators in higher education increasingly view
professions as public crafts and emphasize the
democratic skills of citizen-professionals
Syme SL. Social determinants of health the
community as an empowered partner. Preventing
Chronic Disease 2004 1(1) Accessed December 15,
2003. Available from http//www.cdc.gov/pcd/issu
es/2004/jan/syme.htm Boyte HC. Professions as
public crafts. Wingspread Conference on New
Information Commons Racine, WI Center for
Democracy and Citizenship 2000. Available at
lthttp//www.publicwork.org/pdf/workingpapers/Publi
c20crafts.pdfgt Boyte HC, Kari NN. Turning our
jobs into public work. In Boyte HC, Kari NN,
editors. Building America the Democratic Promise
of Public Work. Philadelphia Temple University
Press 1996. p. 164-188. Ehrlich T. Civic
responsibility and higher education. Phoenix, AZ
Oryx Press, 2000.
49
Is Anyone Really an Outsider?
Outside Expert Citizen Actor
Focus Efficiency of means Ask both why and how
Discourse Technical Political (non-partisan)
Stance Seeing from discipline From the world
Goal Fix problem Create values Develop capacities
Philosophy Positivism Pragmatism
Key actor(s) Expert Citizens (each w/ own expertise)
Skills Disaggregation, analysis Integration, anticipation, action
Boyte HC. Doctoral education for the 21st
century reframing scholarship in mass
communications. Civic Engagement News 20045.
50
Growth of Citizen Actors
Almost everyone knows about the explosion of the
dot-comsbut millions have still not heard the
big story the worldwide explosion of
dot-orgs. More people today have the freedom,
time, wealth, health, exposure, social mobility,
and confidence to address social problems in bold
new ways.
60
-- David Bornstein
Bornstein D. How to change the world social
entrepreneurs and the power of new ideas. New
York Oxford University Press, 2004.
51
Contrasting Strategies for Directing Social
Change
Advocating Mobilizing Organizing
Definition Pleading in anothers behalf Assembling or coordinating for a purpose Arranging systematically for harmonious functioning or united action
Form A voice A following A working whole
Products Special interests Mass movements Public work
In Practice Ad hoc Diminishing s over time Weak accountability Weak commitment to institutional development Single, charismatic leader Weak ties to values and self-interests Ad hoc Diminishing s over time Weak accountability Weak commitment to institutional development Single, charismatic leader Weak ties to values and self-interests Enduring Increasing s over time Strong accountability Strong commitment to institutional development Many leaders in many networks Strong ties to values and self-interests
52
Navigational VenturesFinlands North Karelia
Project
Puska P. The North Karelia Project 20 year
results and experiences. Helsinki National
Public Health Institute, 1995. National Public
Health Institute. North Karelia international
visitor's programme. National Public Health
Institute, 2003. Available at lthttp//www.ktl.fi/
eteo/cindi/northkarelia.htmlgt.
53
Focusing the Intervention Policy
Policy A Focus on High Risk Individuals
Puska P. The North Karelia Project 20 year
results and experiences. Helsinki National
Public Health Institute, 1995
54
Broad Intervention PolicyNorth Karelia Project
Adapted from Puska P. North Karelia International
Visitors Programme, 2003. Center for Democracy
and Citizenship. The concept and philosophy of
public work. Center for Democracy and
Citizenship, 2001. Available at
lthttp//www.publicwork.org/1_2_philosophy.htmlgt.
55
Directing ChangeNorth Karelia Project
  • Selected Action Strategies
  • Medical services, if necessary
  • Newspaper coverage articles, editorials, letters
  • TV time highly rated 30-45 minute shows (no
    PSAs)
  • Housewives organization cooking and dietary
    choices
  • Opinion leaders role models, support groups,
    public action
  • Tax shifting tobacco, butter, milk
  • Economic Renewal
  • Decline of dairy
  • Rise of berry
  • Rise of vegetable oil and rapeseed oil
  • Rise of healthier breads, cheeses, sausages, etc

Puska P. The North Karelia Project 20 year
results and experiences. Helsinki National
Public Health Institute, 1995.
56
Transforming All Dimensionsof the System
57
Directing ChangeNorth Karelia Project
  • Efforts to Fight Afflictions (design/deliver)
  • Screening
  • Education
  • Risk reduction counseling
  • Medical/pharmaceutical treatment
  • Disease self-management

58
Directing ChangeNorth Karelia Project
  • Efforts to Improve Adverse Living Conditions
    (develop/promote)
  • Tobacco legislation
  • Food-labeling requirements
  • Margarines and oils
  • Low-fat milk
  • Low-fat, low-salt, high-fiber bread
  • Vegetable-containing sausage (with mushrooms)
  • Berry farming and consumption
  • Community competitions, morale, and social norms
  • State welfare system (at the national, regional,
    sub-regional, and local levels)

59
Building PowerNorth Karelia Project
  • Health Professionals
  • Physicians
  • Health Educators
  • Psychologists
  • Epidemiologists
  • Sociologists
  • Hospital administrators
  • Pharmaceutical manufacturers
  • Nurses
  • Rehabilitation therapists
  • Other Citizens
  • Bakers
  • Farmers
  • Grocers
  • Food scientists, manufacturers
  • Restaurant owners
  • Housewives
  • Entertainers
  • Entrepreneurs
  • Journalists, media professionals
  • Teachers
  • School administrators
  • Elected representatives

60
Charting ProgressNorth Karelia Project
Vartiainen E, Puska P, Pekkanen J, Toumilehto J,
Jousilahti P. Changes in risk factors explain
changes in mortality from ischaemic heart disease
in Finland. British Medical Journal
1994309(6946)23-27.
61
Charting ProgressNorth Karelia Project
-49
-68
-73
-44
-71
Puska P. The North Karelia Project 20 year
results and experiences. Helsinki National
Public Health Institute, 1995. National Public
Health Institute. North Karelia international
visitor's programme. National Public Health
Institute, 2003. Accessed May 30, 2004 at
lthttp//www.ktl.fi/eteo/cindi/northkarelia.htmlgt.
62
Framing the Challenge of Health
ProtectionHealth Equity
PERSONPeople living with affliction
Health States Rates
TIME People vulnerable to affliction
PLACE Areas with a recurring problem of affliction
63
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