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Navigating Health Futures in a Dynamic and Democratic World Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc. gov http: //www. cdc. gov/syndemics Syndemics Prevention Network University of Auckland School of Population Health New Zealand Ministry of Health Auckland: September 12 -14, 2007 Wellington: September 19 -21, 2007
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 • Syndemics Prevention Network Questions and Discussion Throughout
Chronic Conditions Here (and Everywhere) Are… • • Interconnected • Increasing • Costly • Debilitating • Deadly • Inequitably distributed • Syndemics Diverse • Prevention Network Common Largely preventable Defy quick fixes and require a sound system-wide strategy to protect health as well as other values
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 devised…It 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? Syndemics Prevention Network Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21 st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002.
Innovation, Pragmatism, and the Promise of “What If…” Thinking "Grant an idea or belief to be true…what concrete difference will its being true make in anyone's actual life? -- William James Positivism • Begins with a theory about the world • Learning through observation and falsification • Asks, “Is this theory true? ” Pragmatism • Begins with a response to a perplexity or injustice in the world • Learning through action and reflection • Asks, “How does this work make a difference? ” 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
Epi·demic • • 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“ • A representation of the cholera epidemic of the nineteenth century. Source: NIH The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work “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 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/vol 12 no 06/05 -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/ Syndemics Prevention Network Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873.
Syn·demic Events Co-occurring • 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 Confounding Connecting* Synergism System Syndemic * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping Syndemics Prevention Network
Tools for Policy Planning & Evaluation Events Increasing: Time Series Models Describe trends • Depth of causal theory Patterns • Robustness for longerterm projection • Value for developing policy insights • Degrees of uncertainty Structure Syndemics Prevention Network Multivariate Stat Models Identify historical trend drivers and correlates Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals
Seeing Syndemics “You think you understand two because you understand 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: Health “Health Policy” “Citizenship” Living Conditions Power to Act – mutually reinforcing health problems “Social Policy” – health status and living conditions – synergy/fragmentation in the health protection system (e. g. , by issues, sectors, organizations, professionals and other citizens) A syndemic orientation clarifies the dynamic and democratic character of public health work • Syndemics Prevention Network 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.
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 21 st 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. Syndemics Prevention Network
Changing (and Accumulating) Views of Population Health What Accounts for Population Health? • God’s will • Humors, miasma, ether • Poor living conditions, immorality (e. g. , ? ) 1840 • Single disease, single cause (e. g. , ? ) 1880 • Single disease, multiple causes (e. g. , ? ) 1950 • 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. , ? ) 1960 1980 2000 Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006. Syndemics Prevention Network Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Exposes the Dynamic and Democratic Dimensions of Public Health Work PUBLIC HEALTH WORK GOVERNING MOVEMENT Social Navigation Directing Change • Who does the work? • By what means? • According to whose values? Charting Progress • How are conditions changing? • In which directions? UNDERSTANDING CHANGE Systems Science • What causes population health problems? Innovative Health Ventures • How are efforts to protect the public’s health organized? • How and when do health systems change (or resist change)? SETTING DIRECTION Public Health What are health leaders trying to accomplish? Syndemics Prevention Network
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. Syndemics Prevention Network
Re-Directing the Course of Change Questions of Social Navigation Prevalence of Diagnosed Diabetes, United States 40 ode Historical Data ? e er h Million people 30 ore F kov Mar M ting l cas W 20 What? Ho 10 0 1980 Why? 1990 2000 Trend is not destiny! 2010 Wh w? Markov Model Constants • Incidence rates (%/yr) • Death rates (%/yr) • Diagnosed fractions (Based on year 2000 data, per demographic segment) o? 2020 2030 2040 2050 Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003; 6: 155 -164. Syndemics Prevention Network 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 2006; 96(3): 488 -494.
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 Syndemics Prevention Network
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
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 remember…That 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 N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at
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 remember…That 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 N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at
Foundations of Directed Change Knowledge Power Morality Facts Self Effects Science Consciousness Conscience Scire, to know Syndemics Prevention Network
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 Mc. Graw-Hill, 2000. Syndemics Prevention Network Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006; 96(3): 452 -458.
Broad Dynamics of the Health Protection Enterprise Prevalence of Vulnerability, Risk, or Disease 100% Values for Health & Equity Size of the Safer, Healthier Population B Taking the Toll R Potential Threats Drivers of Growth B Prevalence of Vulnerability, Risk, or Disease Responses to Growth Health Protection Efforts B - Obstacles Resources & Resistance R Reinforcers Broader Benefits & Supporters 0% Time Syndemics Prevention Network To understand govern health trajectories over time, our concepts and methods for policy analysis must encompass the basic features of this dynamic and democratic system
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 Syndemics Prevention Network Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006; 96(3): 505 -514. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971; 73(3): 53 -68.
Defining Keywords Policy Resistance is… “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. Syndemics Prevention Network
Systems Archetype “Fixes that Fail” + Problem Symptom + - B Fix - + Delay R Unintended Consequence Syndemics Prevention Network + Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc. , 1994. Characteristic Behavior: Better before Worse
“Fixes that Fail” in Public Health Vocabulary The Risk of Targeted Interventions + - Health Problem + What issues tend to be exclude d? Syndemics Prevention Network Targeted Response B - R + Exclusions Delay +
Some Categories of Exclusions Social Disparity & Disconnection Disorientation Political Conceptual Disarray Organizational Together, these forces may seriously undermine the effectiveness of health protection policy Syndemics Prevention Network
How Many Triangles Do You See? Syndemics Prevention Network Wickelgren I. How the brain 'sees' borders. Science 1992; 256(5063): 1520 -1521.
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.
The Weight of Boundary Judgments Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971; 73(3): 53 -68. Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at
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 1990 s and beyond. System Dynamics Review 1993; 9(2): 113 -134. Available at
Seeking High-Leverage Policies “Give me a firm place to stand 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. Syndemics Prevention Network Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at
Navigational Ventures Finland’s North Karelia Project Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995. Syndemics Prevention Network National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at
Focusing the Intervention Policy A: Focus on High Risk Individuals Policy B: Focus on Risk Conditions for All Syndemics Prevention Network Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995
Broad Intervention Policy North Karelia Project Individual Effort Disease Burden Public Work Adapted from Puska P. North Karelia International Visitors’ Programme, 2003. Syndemics Prevention Network Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at
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. Syndemics Prevention Network
Transforming All Dimensions of the System Efforts to Fight Afflictions Efforts to Build Power Health Power to Act Living Conditions Efforts to Improve Adverse Living Conditions Syndemics Prevention Network
Directing Change North Karelia Project Efforts to Fight Afflictions (design/deliver) • Screening • Education • Risk reduction counseling • Medical/pharmaceutical treatment • Disease self-management Syndemics Prevention Network
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) Syndemics Prevention Network
Building Power North Karelia Project Health Professionals • Physicians • Health Educators • Psychologists • Epidemiologists • Sociologists • Hospital administrators • Pharmaceutical manufacturers • Nurses • Rehabilitation therapists Syndemics Prevention Network Other Citizens • Bakers • Farmers • Grocers • Food scientists, manufacturers • Restaurant owners • Housewives • Entertainers • Entrepreneurs • Journalists, media professionals • Teachers • School administrators • Elected representatives
Charting Progress North Karelia Project Syndemics Prevention Network 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 1994; 309(6946): 23 -27.
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. Syndemics Prevention Network National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Accessed May 30, 2004 at
Framing the Challenge of Chronic Illness PERSON People living with affliction TIME People vulnerable to affliction Syndemics Prevention Network Health States & Rates PLACE Areas with a recurring problem of affliction
Health System Dynamics Public Work Society's Health Response General Protection Targeted Protection Primary Prevention Demand for response Becoming safer and healthier Safer Healthier People Becoming vulnerable Tertiary Prevention Secondary Prevention Vulnerable People Becoming afflicted Afflicted without Complications Developing complications Afflicted with Complications Adverse Living Conditions Dying from complications “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. " -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. 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 Gerberding JL. FY 2008 CDC Congressional Budget Hearing. Testimony before the Committee on Appropriations, it? CDC Futures Health Systems Workgroup; and Related Agencies, United States House of Subcommittee on Labor, Health and Human Services, Education Atlanta, GA; 2003. Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Syndemics Prevention Network Representatives; Washington, DC; March 9, 2007. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006; 96(3): 452 -458. Julie Gerberding
Balancing Two Major Areas of Emphasis Public Work Healthy Public Policy & Public Work Medical and Public Health Policy Society's Health Response General Protection Targeted Protection Primary Prevention Tertiary Prevention Secondary Prevention Demand for response Becoming safer and healthier Safer Healthier People Becoming vulnerable Vulnerable People Afflicted without Becoming Complications Developing Complications complications afflicted Dying from complications Adverse Living Conditions DEMOCRATIC SELF-GOVERNANCE World of Transforming… • Deprivation • Dependency • Violence • Disconnection • Environmental decay • Stress • Insecurity • Etc… Syndemics Prevention Network By Strengthening… • Leaders and institutions • Foresight and precaution • The meaning of work • Mutual accountability • Plurality • Democracy • Freedom • Etc… MANAGEMENT OF DISEASES AND RISKS World of Providing… • Education • Screening • Disease management • Pharmaceuticals • Clinical services • Physical and financial access • Etc… Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.
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). Syndemics Prevention Network 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/syndemics
Choice and Non-Choice “Choices are always made from among alternatives presented by the social environment, or by circumstances that were themselves not chosen…When 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 1999; 29(2): 261 -93. Syndemics Prevention Network
Understanding Health as Public Work - Citizen Involvement in Public Life Society's Health Response General Protection Targeted Protection Primary Prevention - Tertiary Prevention Secondary Prevention Demand for response Becoming safer and healthier Safer Healthier People Becoming vulnerable Vulnerable People Adverse Living Conditions Fraction of Adversity, Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) Syndemics Prevention Network Becoming afflicted Afflicted without Complications Developing complications Afflicted with Complications Dying from complications Vulnerable and Afflicted People Social Division Public Strength
Evaluating Dynamic, Democratic Policies Public Work - Citizen Involvement in Public Life Society's Health Response General Protection Targeted Protection Primary Prevention Secondary Prevention Tertiary Prevention Demand for response Becoming safer and healthier Safer Healthier People Becoming vulnerable Vulnerable People Adverse Living Conditions Fraction of Adversity, Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) Becoming afflicted Afflicted without Complications Developing complications Afflicted with Complications Dying from complications Vulnerable and Afflicted People Social Division How can we learn about the consequences of alternative policies in a system of this kind? Syndemics Prevention Network Public Strength
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 1960 s • Population health applications starting mid-1970 s 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 Mc. Graw-Hill, 2000. Syndemics Prevention Network Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006; 96(3): 452 -458.
Learning In and About Dynamic Systems Real World • Unknown structure • Dynamic complexity • Time delays • Impossible experiments Virtual World • Known structure • Implementation • Controlled experiments • Game playing Information Decisions • Enhanced learning • Inconsistency Feedback • Short term • Inability to infer Strategy, Structure, Decision Rules dynamics from mental models Mental Models • Selected • Missing • Delayed • Biased • Ambiguous • Misperceptions • Unscientific • Biases • Defensiveness Sterman JD. Learning in and about complex systems. System Dynamics Review 1994; 10(2 -3): 291 -330. Syndemics Prevention Network Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin Mc. Graw-Hill, 2000.
A Model Is… An inexact representation of the real thing They help us understand, explain, anticipate, and make decisions “All models are wrong, some are useful. ” Syndemics Prevention Network -- George Box
Selected CDC Projects Featuring System Dynamics Modeling • Syndemics Mutually reinforcing afflictions • Diabetes In an era of rising obesity • Obesity Lifecourse consequences of changes in caloric balance • Grantmaking Scenarios Timing and sequence of outside assistance • Upstream-Downstream Effort Balancing disease treatment with prevention/protection • Healthcare Reform • Infant Health Fetal and infant morbidity/mortality Relationships among cost, quality, equity, and health status • 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.
Simulations for Learning in Dynamic Systems Multi-stakeholder Dialogue Dynamic Hypothesis (Causal Structure) Plausible Futures (Policy Experiments) Obese fraction of Adults (Ages 20 -74) Fraction of popn 20 -74 50% 40% 30% 20% 10% 0% 1970 1980 1990 2000 2010 2020 2030 2040 2050 Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000. Syndemics Prevention Network Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin Mc. Graw-Hill, 2000.
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 Syndemics Prevention Network
CDC Diabetes System Modeling Project Discovering Stock-Flow Dynamics Through Action Labs Syndemics Prevention Network 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 2006; 96(3): 488 -494.
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 planners—federal, state, and local Done in conjunction with Sustainability Institute and the Center for Public Health Practice at Emory University Syndemics Prevention Network 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 2006; 96(3): 488 -494.
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 Civic Participation Forces Outside the Community • Social cohesion • Responsibility for others • Macroeconomy, employment • Food supply • Advertising, media • National health care • Racism • Transportation policies • Voluntary health orgs • Professional assns • University programs • National coalitions Health Care & Public Health Agency Capacity Personal Capacity Local Living Conditions • Understanding • Motivation • Social support • Literacy • Physio-cognitive function • Life stages • Availability of good/bad food • Availability of phys activity • Comm norms, culture (e. g. , responses to racism, acculturation) • Safety • Income • Transportation • Housing • Education Health Care Utilization Metabolic Stressors • Nutrition • Physical activity • Stress Syndemics Prevention Network • Provider supply • Provider understanding, competence • Provider location • System integration • Cost of care • Insurance coverage Population Flows • Baseline Flows • Ability to use care (match of patients and providers, language, culture) • Openness to/fear of screening • Self-management, monitoring • Percent of patients screened • Percent of people with diabetes under control
Overview of Diabetes Stock-and-Flow Model Burden of Diabetes Total Prevalence (people with diabetes) People with Normal Blood Sugar Levels Prediabetes Onset e People with Prediabetes Recovering from Prediabetes d Obesity in the General Population People with Diagnosis Undiagnosed b Diabetes People with Diagnosed Diabetes Prediabetes Detection & Management Diabetes Detection Volume Syndemics Deaths a Deaths Inflow Prevention Network Unhealthy Days (per person with diabetes) Developing Diabetes Onset c Costs (per person with diabetes) Outflow Diabetes Management
Overview of Diabetes Stock-and-Flow Model This larger view takes us beyond standard epidemiological models and most intervention programs People with Normal Blood Sugar Levels Pre. Diabetes Onset e Total Prevalence (people with diabetes) People with Prediabetes Diabetes Onset c Costs (per person with diabetes) Unhealthy Days (per person with diabetes) Developing Recovering from Pre. Diabetes d Obesity in the General Population Burden of Diabetes People with Diagnosis Undiagnosed b Diabetes People with Diagnosed Diabetes Deaths a Deaths Prediabetes Detection & Management Diabetes Detection Diabetes Management Standard boundary Inflow Volume Syndemics Prevention Network Outflow
Using Available Data to Ground the Model Information Sources Data • Population growth and death rates U. S. Census • Fractions elderly, black, hispanic • Health insurance coverage National Health Interview Survey National Health and Nutrition Examination Survey Behavioral Risk Factor Surveillance System Professional Literature Syndemics Prevention Network • Diabetes prevalence • Diabetes detection • Prediabetes prevalence • Obesity prevalence • Eye exam and foot exam • Taking diabetes medications • Unhealthy days (HRQOL) • Effects of risk factors and mgmt on onset, complications, and costs • Direct and indirect costs of diabetes
One way we establish the model’s value is by looking at its ability to reproduce historical data (2 variables out of 10 such comparisons) Diagnosed diabetes per thousand total popn 60 Diagnosed fraction of diabetes popn 1 Model 45 NHIS 0. 8 Model 30 0. 6 15 0 1984 1988 1992 1996 2000 NH II 0. 4 2004 1980 1984 NHANES III 1988 1992 Syndemics Homer J. Reference guide for the CDC Diabetes System Model. Atlanta, GA: Division of Diabetes Translation, Centers for Prevention; August, 2006. <
Healthy People 2010 Diabetes Objectives: What Can We Accomplish? Baseline Reduce Diabetes–related Deaths Among Diagnosed (5 -6) Increase Diabetes Diagnosis (5 -4) Reduce New Cases of Diabetes (5 -2) Reduce Prevalence of Diagnosed Diabetes (5 -3) 8. 8 per 1, 000 68% 3. 5 per 1, 000 40 per 1, 000 HP 2010 Target Percent Change 7. 8 -11% 80% +18% 2. 5 -29% 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/Volume 1/05 Diabetes. htm Syndemics Prevention Network
A History of Missed Goals People with Diagnosed Diabetes per 1, 000 Popn Diagnosed Diabetes Prevalence per Thousand Adults Meet HP 2010 detection goal 60 Status quo (simulated) Meet HP 2010 onset goal 50 +25% 40 lanc il Surve IS) a (NH e dat +33% -11% 30 HP 2000 prevalence goal -38% HP 2010 prevalence goal 20 1985 1990 1995 2000 2005 2010 Time (Years) Simulations have helped diabetes planners set more realistic goals. Syndemics Prevention Network 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.
Connecting the Objectives Population Flows and Dynamic Accounting 101 People without Diabetes The targeted 29% reduction in diagnosed onset can only slow the growth in prevalence Initial Onset People with Undiagnosed Diabetes With a diagnosed onset flow of 1. 1 mill/yr Diagnosed As would stepped-up detection effort Onset People with Diagnosed Diabetes Reduced death would add further to prevalence It is impossible for any policy to reduce prevalence 38% by 2010! Syndemics Prevention Network Dying from Diabetes Complications 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.
Policy Testing…and Reason for Hope Monthly Unhealthy Days from Diabetes per Thousand U. S. Morbidity from Diabetes Simulated 1980 -2050 600 Base 500 l Contro Primary prevention 400 Combination 300 200 1980 Syndemics Prevention Network 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.
The Modeling Process is Having an Impact • Budget for primary prevention was doubled – from meager to modest • HP 2010 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 Syndemics Prevention Network
Expanding Public Health Science “Public health imagination involves using science to expand the boundaries of what is possible. ” -- Michael Resnick Syndemic Orientation Causal Mapping Governing Dynamics Boundary Critique Epidemic Orientation Dynamic Modeling Democratic Public Work People in Places Navigational Freedoms Syndemics Prevention Network Plausible Futures
Power Has to be Organized “Academics and pundits love to throw around the term ‘social capital’ and debate its nuances, but most of them couldn’t organize a block party. ” -- Ed Chambers ET, Cowan MA. Roots for radicals. New York: Continuum, 2003. , p. 65. Syndemics Prevention Network
Growth of Citizen Leaders “Almost everyone knows about the explosion of the dot-coms…but 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 60% mobility, and confidence to address social problems in bold new ways. ” -- David Bornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004. Syndemics Prevention Network
Contrasting Strategies for Directing Social Change Advocating Products • Arranging systematically for harmonious functioning or united action • A voice • A following • A working whole • Special interests • Mass movements • Public work • Ad hoc • Diminishing #s over time • Weak accountability • Weak commitment to institutional In Practice development • Single, charismatic leader • Weak ties to values and self-interests Syndemics Prevention Network Organizing • Assembling or coordinating for a purpose • Pleading in Definition another’s behalf Form Mobilizing • Enduring • Increasing #s over time • Strong accountability • Strong commitment to institutional development • Many leaders in many networks • Strong ties to values and self-interests
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.
Organizing Power IAF Principles • • 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 • Syndemics Power precedes programs • Prevention Network Broad-based, multi-issue orgs, built to win and built to last Organize, disorganize, reorganize Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004.
Organizing Power IAF Organizing Activities • • Recruit institutions and allies • Pay dues • Do research (problems, power, interests) • Act on winnable issues • Evaluate every action • Syndemics Find and train leaders • Prevention Network Have relational meetings Organize, disorganize, reorganize Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004.
Revisiting our Hypothesis of Health System Dynamics Incorporating Public vs. Professional Concern Syndemics Prevention Network
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). Syndemics Prevention Network 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/syndemics
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). Syndemics Prevention Network 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/syndemics
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). Syndemics Prevention Network 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/syndemics
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). Syndemics Prevention Network 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/syndemics
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). Syndemics Prevention Network 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/syndemics
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). Syndemics Prevention Network 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/syndemics
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). Syndemics Prevention Network 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/syndemics
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 political—but non-partisan—and cannot be done by professionals alone. Syndemics Prevention Network
Voyage of Rediscovery Hawaii – Aotearoa, 1985 -1987 “I can see how connected the Māori 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 Syndemics Prevention Network Thompson N. The voyage of rediscovery: 1985 -1987. Polynesian Voyaging Society, 2005. Available at