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Title: An Introduction to Syndemics: Implications for Health Promotion


1
An Introduction to Syndemics Implications for
Health Promotion
Bobby Milstein Syndemics Prevention
Network Centers for Disease Control and
Prevention bmilstein_at_cdc.gov http//www.cdc.gov/sy
ndemics
Introduction to Health Promotion (PH
7016) Georgia State University April 19,
2006 Atlanta, GA
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 principles and
methodologies support this perspective
(scientifically, politically, morally)? What
effects do these ways of thinking and acting have
on individuals and in the world at large?
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
Theory What 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 other 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
About the ideal goal of human effort there
exists in our civilization and, for nearly thirty
centuries, there has existed a very general
agreement.Not so with regard to the roads which
lead to that goal. Here unanimity and certainty
give place to utter confusion, to the clash of
contradictory opinions, dogmatically held and
acted upon with the violence of fanaticism.
-- Aldous Huxley
Huxley A. Ends and means an inquiry into the
nature of ideals and into methods employed for
their realization. New York, NY Harper, 1937.
18
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
NJ Princeton University Press, 1988.
19
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
    Problems Problem, problem solver, response
  • Efforts to Organize a System that Assures the
    Conditions for Health Dynamic 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.
20
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.
21
Even the Greatest Gains are Fragile

22
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.
23
Specialization A Proven Problem Solving Approach
  • Identify disease
  • Determine causes
  • Develop and test interventions
  • Implement programs and policies
  • Repeat steps 1-4, as necessary!

24
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
25
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.
26
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. 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.
27
Questioning the Character of Public Health Work
PUBLIC HEALTH WORK
Innovative Health Ventures
28
Syndemic Orientation Working 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.
29
Core Public Health Functions Under a Syndemic
Orientation
ASSESSMENT
Social Navigation
Network Analysis
Categorical Orientation
Syndemic Orientation
System Dynamics
POLICY DEVELOPMENT
ASSURANCE
30
Solutions Can 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.
31
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.
32
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 crafted)

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.
33
How Many Triangles Do You See?
Wickelgren I. How the brain 'sees' borders.
Science 1992256(5063)1520-1521.
34
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
35
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
36
You Can Argue with Einstein
For certain purposes, public judgment should
carry more weight than expert opinion and not
simply because the majority may have more
political power than the individual expert but
because the publics claim to know is actually
stronger than the experts...the judgment of the
general public can, under some conditions, be
equal or superior in quality to the judgment of
experts and elites who possess far more
information, education, and ability to articulate
their views.
-- Daniel Yankelovich
Yankelovich D. Coming to public judgment making
democracy work in a complex world. 1st ed
Syracuse, NY Syracuse University Press, 1991. p.
220.
37
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.
38
What causes the behaviors we observe?
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
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.
42
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
43
What processes or phenomena might we need a
macroscope to see?
44
Tools for Policy Analysis
45
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.
46
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
47
Balancing Two Areas of Emphasis
48
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)?
49
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.
50
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.
51
Re-Directing the Course of Change Questions from
System Modeling and Social Navigation
Where?
How?
Why?
Who?
2020
2010
52
Simulations for Learning in Dynamic
Systems Diabetes 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.
53
Setting Realistic Expectations HP 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) 3.5 per 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
54
History and Futures for Diabetes
Prevalence Reported 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
55
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
prevalence 38 by 2010!
And a death flow of 0.5 mill/yr (4/yr rate)
56
Counterintuitive Dynamics of the Diabetes System
  • The better you do under the current strategy, the
    more you miss a primary goal
  • Effective detection and disease management
    increase diagnosed prevalence
  • Over the next decade, enormous success in primary
    prevention wont actually reduce the overall
    burden of diabetes
  • It will lead it to grow more slowly
  • What helps in short term doesnt help much in the
    long term. And vice versa.
  • Disease management works in short primary
    prevention works in long

57
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.
58
Enlarging the Scope of Public Health Work
Public health imagination involves using science
to expand the boundaries of what is
possible. -- Michael Resnick
Epidemic Orientation
59
To Sum Up
We are as confused as ever, but on a higher
level and about more important things.
Humor Consultants, Inc.
60
For Additional Information http//www.cdc.gov/synd
emics
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