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Navigating Health Futures in a Dynamic and Democratic World

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Title: Navigating Health Futures in a Dynamic and Democratic World


1
Navigating Health Futures in a Dynamic and
Democratic World
Bobby Milstein Syndemics Prevention
Network Centers for Disease Control and
Prevention bmilstein_at_cdc.gov http//www.cdc.gov/sy
ndemics
University of Auckland School of Population
Health New Zealand Ministry of Health Auckland
September 12-14, 2007 Wellington September
19-21, 2007
2
Topics for Today
  • Principles of a Syndemic Orientation
  • A Navigational View of Public Health Work
  • Dealing with Dynamic Complexity
  • Policy resistance
  • Boundary critique
  • Crafting high-leverage interventions
  • Causal mapping and simulation modeling
  • Building power
  • Illustrations
  • North Karelia Project
  • CDC Diabesity Modeling
  • Industrial Areas Foundation
  • Questions and Discussion Throughout

3
Chronic Conditions Here (and Everywhere) Are
  • Common
  • Diverse
  • Interconnected
  • Increasing
  • Costly
  • Debilitating
  • Deadly
  • Inequitably distributed
  • Largely preventable

Defy quick fixes and require a sound system-wide
strategy to protect health as well as other values
4
How to Meet the Challenge?
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? How are innovators
approaching the challenge of assuring more
healthful and equitable conditions?
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.
5
Innovation, Pragmatism, and the Promise of What
If Thinking
"Grant an idea or belief to be truewhat concrete
difference will its being true make in anyone's
actual life? -- William James
These are conceptual, methodological, and moral
orientations, which shape how we think, how we
act, how we learn, and what we value
Shook J. The pragmatism cybrary. 2006. Available
at lthttp//www.pragmatism.org/gt. Addams J.
Democracy and social ethics. Urbana, IL
University of Illinois Press, 2002. West C. The
American evasion of philosophy a genealogy of
pragmatism. Madison, WI University of Wisconsin
Press, 1989.
6
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.
7
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 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
8
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

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
9
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 transformations in 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
10
Working Definition 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
  • 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.
11
Changing (and Accumulating) Views of Population
Health What Accounts for Poor Population Health?
  • Gods will
  • Humors, miasma, ether
  • Poor living conditions, immorality (e.g., ?)
  • Single disease, single cause (e.g., ?)
  • Single disease, multiple causes (e.g., ?)
  • Single cause, multiple diseases (e.g., ?)
  • Multiple causes, multiple diseases (but no
    feedback dynamics) (e.g., ?)
  • Dynamic feedback among afflictions, living
    conditions, and public strength (e.g., ?)

Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world
Doctoral Dissertation. Cincinnati, OH Union
Institute University 2006. Richardson GP.
Feedback thought in social science and systems
theory. Philadelphia, PA University of
Pennsylvania Press, 1991.
12
Exposes the Dynamic and Democratic Dimensions of
Public Health Work
PUBLIC HEALTH WORK
Innovative Health Ventures
13
Seeing Beyond the Probable
Most organizations plan around what is most
likely. In so doing they reinforce what is, even
though they want something very
different. -- Clement Bezold
  • Possible What may happen?
  • Plausible What could happen?
  • Probable What will likely happen?
  • Preferable What 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.
14
Re-Directing the Course of Change Questions of
Social Navigation
Prevalence of Diagnosed Diabetes, United States
40
Where?
30
Million people
20
What?
How?
  • Markov Model Constants
  • Incidence rates (/yr)
  • Death rates (/yr)
  • Diagnosed fractions
  • (Based on year 2000 data, per demographic segment)

10
Trend is not destiny!
Who?
Why?
0
1980
1990
2000
2010
2020
2030
2040
2050
Honeycutt A, Boyle J, Broglio K, Thompson T,
Hoerger T, Geiss L, Narayan K. A dynamic markov
model for forecasting diabetes prevalence in the
United States through 2050. Health Care
Management Science 20036155-164. 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.
15
Reconnecting with a Voyaging Tradition
Nainoa Thompson, who studied under Mau Pialug,
became the first Hawaiian navigator in over 500
years to guide a canoe over this traditional
route without instruments.
-- Polynesian Voyaging Society
16
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. Doctoral
dissertation. Cincinnati, OH Union Institute and
University. November, 2006.
17
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.
18
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.
19
Foundations of Directed Change
Science
20
Chronic Conditions are Classic Examples of
Dynamically Complex Problems
  • Differences between short- and long-term
    consequences of an action
  • Time delays (e.g., developmental period, time to
    detect, time to respond)
  • Accumulations (e.g., prevalences, resources,
    attitudes)
  • Behavioral feedback (e.g., reactions by various
    actors)
  • Nonlinear causal relationships (e.g., threshold
    effects, saturation effects)
  • Differences or inconsistencies in goals/values
    among stakeholders

Sterman JD. Business dynamics systems thinking
and modeling for a complex world. Boston, MA
Irwin McGraw-Hill, 2000. Homer JB, Hirsch GB.
System dynamics modeling for public health
background and opportunities. American Journal of
Public Health 200696(3)452-458.
21
Broad Dynamics of the Health Protection
Enterprise
Prevalence of Vulnerability, Risk, or Disease
100
Values for Health Equity
Size of the Safer, Healthier Population
Potential Threats
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
22
What Do These Observations Having in Common?
  • Low tar and low nicotine cigarettes Lead to
    greater carcinogen intake
  • Fad diets Produce diet failure and weight gain
  • Road building to ease congestion Attracts
    development, increases traffic, delays,
    pollution, and urban sprawl
  • Antibiotic pesticide use Stimulate resistant
    strains
  • Air-conditioning use Raises neighborhood heat
  • Forest fire suppression Builds 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.
23
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.
24
Systems Archetype
Fixes that Fail
Fix
Characteristic Behavior Better before Worse
Kim DH. Systems archetypes at a glance.
Cambridge, MA Pegasus Communications, Inc., 1994.
25
Fixes that Fail in Public Health Vocabulary
The Risk of Targeted Interventions

Health
Targeted Response
B
Problem
-

What issues tend to be excluded?
Exclusions

26
Some Categories of Exclusions
Social
Disorientation
Conceptual
Political
Organizational
Together, these forces may seriously undermine
the effectiveness of health protection policy
27
How Many Triangles Do You See?
Wickelgren I. How the brain 'sees' borders.
Science 1992256(5063)1520-1521.
28
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
29
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.
30
Implications for Policy Planning and Evaluation
  • Insights from the Overview Effect
  • Maintain a particular analytic distance
  • Not too close to the details of service delivery,
    but not too far as to miss the internal pressures
    of vulnerability, capacity, and health status
  • Potential to explain temporal patterns (e.g.,
    better before worse)
  • Structure determines behavior
  • Potential to avoid scapegoating

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.
31
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.
32
Navigational Ventures Finlands 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.
33
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
34
Broad Intervention Policy North 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.
35
Directing Change North 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.
36
Transforming All Dimensions of the System
37
Directing Change North Karelia Project
  • Efforts to Fight Afflictions (design/deliver)
  • Screening
  • Education
  • Risk reduction counseling
  • Medical/pharmaceutical treatment
  • Disease self-management

38
Directing Change North 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)

39
Building Power North 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

40
Charting Progress North 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.
41
Charting Progress North 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.
42
Framing the Challenge of Chronic Illness
PERSON People living with affliction
Health States Rates
TIME People vulnerable to affliction
PLACE Areas with a recurring problem of affliction
43
Health System Dynamics
One major task that CDC is intending to address
is balancing this portfolio of our health system
so that there is much greater emphasis placed on
health protection, on making sure that we invest
the same kind of intense resources into keeping
people healthier or helping them return to a
state of health and low vulnerability as we do to
disease care and end of life care." -- Julie
Gerberding
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 Work Group Atlanta,
GA December 3, 2003. Gerberding JL. CDC's
futures initiative. Atlanta, GA Public Health
Training Network April 12, 2004. Gerberding JL.
FY 2008 CDC Congressional Budget Hearing.
Testimony before the Committee on Appropriations,
Subcommittee on Labor, Health and Human Services,
Education and Related Agencies, United States
House of Representatives Washington, DC March
9, 2007. Homer JB, Hirsch GB. System dynamics
modeling for public health background and
opportunities. American Journal of Public
Health 200696(3)452-458.
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.
44
Balancing Two Major Areas of Emphasis
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Doctoral dissertation. Cincinnati, OH Union
Institute and University. November, 2006.
45
Seeing Conditions as Freedoms
  • Adverse living conditions are circumstances that
    inhibit people's freedom to be safe and healthy
    and develop their full potential
  • They include, at a minimum, any deviation from
    prerequisite conditions for life and human
    dignity (e.g., physical extremes, violence,
    deprivation, disconnection)
  • Phenomena like hunger, homelessness, joblessness,
    illiteracy, war, environmental decay, and various
    forms of injustice, including racism, are all
    examples of adverse living conditions

Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
46
Choice and Non-Choice
Choices are always made from among alternatives
presented by the social environment, or by
circumstances that were themselves not
chosenWhen we recognize the elements of
non-choice in choice, we can escape the
contradiction between social causation and
individual responsibility and understand the
interactiveness of the two.
Levins R, Lopez C. Toward an ecosocial view of
health. International Journal of Health Services
199929(2)261-93.
47
Understanding Health as Public Work
Public Work
-
Public
Society's Health
Strength
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
Social Division
48
Evaluating Dynamic, Democratic Policies
How can we learn about the consequences of
alternative policies in a system of this kind?
49
System Dynamics Was Developed to Address
Problems Marked By Dynamic Complexity
  • Origins
  • Jay Forrester, MIT, Industrial Dynamics, 1961
    (One of the seminal books of the last 20
    years.-- NY Times)
  • Public policy applications starting late 1960s
  • Population health applications starting mid-1970s
  • Good at Capturing
  • Differences between short- and long-term
    consequences of an action
  • Time delays (e.g., incubation period, time to
    detect, time to respond)
  • Accumulations (e.g., prevalences, resources,
    attitudes)
  • Behavioral feedback (reactions by various actors)
  • Nonlinear causal relationships (e.g., threshold
    effects, saturation effects)
  • Differences or inconsistencies in goals/values
    among stakeholders

Sterman JD. Business dynamics systems thinking
and modeling for a complex world. Boston, MA
Irwin McGraw-Hill, 2000. Homer JB, Hirsch GB.
System dynamics modeling for public health
background and opportunities. American Journal of
Public Health 200696(3)452-458.
50
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.
51
A Model Is
  • An inexact representation of the real thing

All models are wrong, some are useful. --
George Box
52
Selected CDC Projects Featuring System Dynamics
Modeling
  • Grantmaking Scenarios Timing and sequence of
    outside assistance
  • Upstream-Downstream Effort Balancing disease
    treatment with prevention/protection
  • Healthcare Reform Relationships among cost,
    quality, equity, and health status
  • Syndemics Mutually reinforcing afflictions
  • Diabetes In an era of rising obesity
  • Obesity Lifecourse consequences of changes in
    caloric balance
  • Infant Health Fetal and infant morbidity/mortality
  • Polio Reintroductions after eradication
  • Heart Disease and Stroke Preventing and managing
    multiple risks, in context

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
.
53
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.
54
Model Uses and Audiences
  • Set Better Goals (Planners Evaluators)
  • Identify what is likely and what is plausible
  • Estimate intervention impact time profiles
  • Evaluate resource needs for meeting goals
  • Support Better Action (Policymakers)
  • Explore ways of combining policies for better
    results
  • Evaluate cost-effectiveness over extended time
    periods
  • Increase policymakers motivation to act
    differently
  • Develop Better Theory and Estimates (Researchers)
  • Integrate and reconcile diverse data sources
  • Identify causal mechanisms driving system
    behavior
  • Improve estimates of hard-to-measure or hidden
    variables

55
CDC Diabetes System Modeling Project Discovering
Stock-Flow Dynamics Through Action Labs
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.
56
CDC Diabetes System Modeling Project
  • Diabetes programs face tough challenges and
    questions
  • With rapid growth in prevalence, is improved
    control good enough?
  • Studies show primary prevention is possible, but
    how much impact in practice and at what cost?
  • How best to balance interventions?
  • Model developed with program planners, diabetes
    researchers, and epidemiologists
  • Model-based learning lab workshops for
    plannersfederal, state, and local

Done in conjunction with Sustainability Institute
and the Center for Public Health Practice at
Emory University
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.
57
We Convened a Model-Scoping Group of 45 CDC
professionals and epidemiologists in December
2003 to Explore the Full Range of Forces Driving
Diabetes Behavior over Time
58
Overview of Diabetes Stock-and-Flow Model
Developing
d
Inflow
Outflow
59
Overview of Diabetes Stock-and-Flow Model
Developing
Developing
Diabetes
Onset
People with
c
Prediabetes
d
Inflow
Outflow
60
Using Available Data to Ground the Model
Information Sources Data
U.S. Census Population growth and death rates Fractions elderly, black, hispanic Health insurance coverage
National Health Interview Survey Diabetes prevalence Diabetes detection
National Health and Nutrition Examination Survey Prediabetes prevalence Obesity prevalence
Behavioral Risk Factor Surveillance System Eye exam and foot exam Taking diabetes medications Unhealthy days (HRQOL)
Professional Literature Effects of risk factors and mgmt on onset, complications, and costs Direct and indirect costs of diabetes
61
One way we establish the models value is by
looking at its ability to reproduce historical
data (2 variables out of 10 such comparisons)
Diagnosed diabetes per thousand total popn
Diagnosed fraction of diabetes popn
60
1
Model
45
NHIS
0.8
Model
30
0.6
15
0
0.4
1980
1984
1988
1992
1996
2000
2004
1980
1984
1988
1992
1996
2000
2004
Homer J. Reference guide for the CDC Diabetes
System Model. Atlanta, GA Division of Diabetes
Translation, Centers for Disease Control and
Prevention August, 2006. ltlthttp//sustainer.org/p
ubs/diabetessystemreference.pdfgt.
62
Healthy People 2010 Diabetes Objectives What Can
We Accomplish?
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
63
A History of Missed Goals
Diagnosed Diabetes Prevalence per Thousand Adults
Meet HP2010 detection goal
60
Status quo (simulated)
Meet HP2010 onset goal
50
25
33
People with Diagnosed Diabetes per 1,000 Popn
40
Surveillance data (NHIS)
-11
30
HP 2000 prevalence goal
HP 2010 prevalence goal
-38
20
1980
1985
1990
1995
2000
2005
2010
Time (Years)
Simulations have helped diabetes planners set
more realistic goals.
Milstein B, Jones A, Homer J, Murphy D, Essien J,
Seville D. Charting plausible futures for
diabetes prevalence A role for system dynamics
simulation modeling. Preventing Chronic Disease
July 2007. lthttp//www.cdc.gov/pcd/issues/2007/jul
/06_0070gt
64
Connecting the Objectives Population Flows and
Dynamic Accounting 101
People with
People
Undiagnosed
without
Initial
Diabetes
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)
Milstein B, Jones A, Homer J, Murphy D, Essien J,
Seville D. Charting plausible futures for
diabetes prevalence A role for system dynamics
simulation modeling. Preventing Chronic Disease
July 2007. lthttp//www.cdc.gov/pcd/issues/2007/jul
/06_0070gt
65
Policy Testingand Reason for Hope
U.S. Morbidity from Diabetes Simulated 1980-2050
600
Base
500
Control
Primary prevention
Monthly Unhealthy Days from Diabetes per Thousand
400
Combination
300
200
1980
1990
2000
2010
2020
2030
2040
2050
With a combination of improved control and
aggressive primary prevention, growth in the
burden of diabetes could be limited for the next
10 years and for decades beyond.
66
The Modeling Process is Having an Impact
  • Budget for primary prevention was doubled
  • from meager to modest
  • HP2010 prevalence goal has been modified
  • from a large reduction to no change (but still
    not an increase)
  • Research, program, and policy staff are working
    more closely
  • Many new leaders emerging, but truly
    cross-functional teams are still forming
  • State health departments and their partners are
    now engaged
  • initial efforts in 13 states

67
Expanding Public Health Science
Public health imagination involves using science
to expand the boundaries of what is
possible. -- Michael Resnick
Epidemic Orientation
68
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.
69
Growth of Citizen Leaders
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.
70
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
71
Organizing Power IAF Issue Campaigns
  • Living wage
  • Nehemiah Homes
  • Alliance Schools
  • Quest job training
  • Blight removal
  • Environmental cleanup
  • After school programs
  • Smaller high schools

Industrial Areas Foundation. About IAF.
Industrial Areas Foundation, 2004.
lthttp//www.industrialareasfoundation.org/gt.
72
Organizing Power IAF Principles
  • Broad-based, multi-issue orgs, built to win and
    built to last
  • Power precedes programs
  • Never do for others what they can do for
    themselves
  • The world as it is vs. the world as it should be
  • Act to get a specific reaction
  • Public accountability begins with
    self-accountability
  • No permanent allies, no permanent enemies
  • Organize, disorganize, reorganize

Industrial Areas Foundation. About IAF.
Industrial Areas Foundation, 2004.
lthttp//www.industrialareasfoundation.org/gt.
73
Organizing Power IAF Organizing Activities
  • Have relational meetings
  • Find and train leaders
  • Recruit institutions and allies
  • Pay dues
  • Do research (problems, power, interests)
  • Act on winnable issues
  • Evaluate every action
  • Organize, disorganize, reorganize

Industrial Areas Foundation. About IAF.
Industrial Areas Foundation, 2004.
lthttp//www.industrialareasfoundation.org/gt.
74
Revisiting our Hypothesis of Health System
Dynamics Incorporating Public vs. Professional
Concern
75
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
76
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
77
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
78
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
79
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
80
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
81
Health System Dynamics Incorporating Public vs.
Professional Concern
Milstein B. Hygeia's constellation navigating
health futures in a dynamic and democratic world.
Unpublished dissertation. Cincinnati, OH Union
Institute and University April 13, 2006 (draft).
Milstein B, Homer J. System dynamics modeling
work in progress the dynamics of upstream and
downstream. Syndemics Prevention Network,
Centers for Disease Control and Prevention.
Atlanta, GA. Available at http//www.cdc.gov/synd
emics
82
Summary Why is it So Hard to Work Across the
Whole System?
  • Initial Observations
  • Upstream work requires more public concern, which
    is less a reaction to the prevalence of disease
    as to the spread of vulnerability and affliction
    that over many years threaten everybody (think of
    economic decline, inadequate education, unsafe
    housing, sprawl, racism, environmental decay,
    etc.)
  • Long before upstream threats become widely
    apparent, money and other resources have focused
    downstream (where professional expertise and the
    weight of scientific evidence lie)
  • Because of their role as providers of downstream
    services, health professionals do not respond to
    vulnerability and social inequity FOR ITS OWN
    SAKE, in the WAY that ordinary citizens often do
  • Upstream health action involves broad-based
    organizing it is politicalbut non-partisanand
    cannot be done by professionals alone.

83
Voyage of Rediscovery Hawaii Aotearoa, 1985-1987
I can see how connected the Maori are to their
ancestry. And because they are connected to their
past, I believe that it's much easier for them to
see the kind of future they want to voyage to.
-- Nainoa Thompson
Thompson N. The voyage of rediscovery 1985-1987.
Polynesian Voyaging Society, 2005. Available at
lthttp//www.pvs-hawaii.com/newsletters/nl_rediscov
ery.htmgt.
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