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Syndemics, System Science, and the Prospect of Navigating Health Futures Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc. gov http: //www. cdc. gov/syndemics Syndemics Prevention Network Coordinating Center for Health Promotion Centers for Disease Control and Prevention October 29, 2007
Co. CHP Coordinates Many of Our Highest Priorities Need to Connect Groups Focused on… • Diseases/Disabilities arthritis, birth defects, cancer, diabetes, epilepsy, heart disease and stroke, obesity, oral health, mental health • • Places • Sciences • Syndemics Lifestages • Prevention Network Risks National initiatives tobacco, nutrition, physical activity, alcohol, sexual behavior, ACEs, racism, genetics infants, children, adolescents, adults, older adults, reproductive age/pregnancy schools, communities, healthcare settings, global surveillance, prevention research, evaluation, social epidemiology, communications, economics, GIS, genomics, syndemics, wellbeing, quality of life REACH, STEPS, WISEWOMAN, MS Delta, VERB
Imperatives for Protecting Health Typical Current State “Static view of problems that are studied in isolation” Proposed Future State “Dynamic systems and syndemic approaches” “Currently, application of complex systems theories or syndemic science to health protection challenges is in its infancy. ” -- Julie Gerberding Syndemics Prevention Network Gerberding JL. Protecting health: the new research imperative. Journal of the American Medical Association 2005; 294(11): 1403 -1406.
One Observer’s View “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.
Model Ventures Healthy Hawaii Initiative “The Healthy Hawaii Initiative is the only long -term, statewide program to implement a social ecological approach to reduce obesity, increase physical activity, and improve nutrition. ” Percentage Change in Health Indicators Hawaii and US, 1998 -2003 Overweight/ Obese Adults Syndemics Prevention Network Leisure Time Activity 5+ Fruit/Veg per Day Partnership for Prevention. Innovation in prevention awards announced. Washington, DC; October 26, 2006.
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
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
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.
Exploring the Dynamic and Democratic Character 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
Changing (and Accumulating) Views of Population Health What Accounts for Population Health? • God’s will • Humors, miasma, ether • Poor living conditions, immorality (e. g. , sanitation) 1840 • Single disease, single cause (e. g. , germ theory) 1880 • Single disease, multiple causes (e. g. , heart disease) 1950 • Single cause, multiple diseases (e. g. , tobacco) • Multiple causes, multiple diseases (but no feedback dynamics) (e. g. , hierarchical modeling) • Dynamic feedback among afflictions, living conditions, and public strength (e. g. , syndemic orientation) 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.
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 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 • Leverage for change 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 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 Wh o? destiny 2010 2020 w? Markov Model Constants • Incidence rates (%/yr) • Death rates (%/yr) • Diagnosed fractions (Based on year 2000 data, per demographic segment) 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.
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
There Have Been Remarkable Successes in Redirecting the Course of Change Actual and Expected Death Rates for Coronary Heart Disease, 1950– 1998 700 Rate if trend continued Age-adjusted Death Rate per 100, 000 Population 600 500 Peak Rate 400 300 Overall Decline is Linked to… • Reduced smoking 200 100 684, 000 fewer deaths in 1998 alone • Changes in diet Actual Rate • Better diagnosis and treatment • More heath services utilization 50 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003. Syndemics Prevention Network Centers for Disease Control and Prevention. Achievements in public health, 1900 -1999: decline in deaths from heart disease and stroke -- United States, 1900 -1999. MMWR 1999; 48(30): 649 -656. Available at
Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs Consumer Price Indices for Healthcare and the General Economy United States, 1960 -2004 (1960=1) Consumer price index (CPI-U) relative to 1960 16 12 Healthcare 8 4 Total economy 0 1960 Syndemics Prevention Network 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004
Healthcare Cost is Also the Leading Driver of Personal Bankruptcy Total Personal Bankruptcy Filings, United States, 1994 -2006 61% of the filers surveyed failed to seek needed medical treatments American Bankruptcy Institute. Bankruptcy filing statistics: non-business filings. Alexandria, VA: American Bankruptcy Institute; October, 2007.
Worsening Trend in Summary Measures of Population Health Average Number of Adult Unhealthy Days per Month, United States, 1993 -2006 rease 17% inc Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2007. Accessed October 23, 2007 at
Entrenched Inequities Syndemics Prevention Network
Entrenched Inequities Life Expectancy at Birth in the Eight Americas (1982 -2001) Syndemics Prevention Network Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLo. S Med 2006; 3(9). Available at
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 Healthful Conditions for All Dynamic interaction among multiple problems, problem solvers, and responses Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988. Institute of Medicine. The future of the public's health in the 21 th century. Washington, DC: National Academy Press, 2002. Syndemics Prevention Network Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.
Looking Through the Macroscope “The macroscope filters details and amplifies that which links things together. It is not used to make things larger or smaller but to observe what is at once too great, too slow, and too complex for our eyes. ” -- Joèl de Rosnay J. The macroscope: a book on the systems approach. Principia Cybernetica, 1997.
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, but not too far as be insensitive to internal pressures • Potential to anticipate temporal patterns (e. g. , better before worse) • Structure determines behavior • Potential to avoid scapegoating or lionizing Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. Richmond B. Systems thinking: critical thinking skills for the 1990 s and beyond. System Dynamics Review 1993; 9(2): 113 -134. Available at
John Snow Heroic Success or Cautionary Tale? 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. " Centers for Disease Control and Prevention. 150 th anniversary of John Snow and the pump handle. MMWR 2004; 53(34): 783. Available at
John Snow Heroic Success or Cautionary Tale? Syndemics Prevention Network Galea S. Macrosocial determination of population health: the example of urbanization. NCEH/ATSDR Director's Science Seminar Series; Atlanta, GA: Centers for Disease Control and Prevention; February 7, 2007.
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
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
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 Problems Among People in Places Over Time Navigational Freedoms Syndemics Prevention Network Plausible Futures
Working Harder to Achieve Health Protection…Health Equity Gerberding JL. CDC: protecting people's health. Director's Update; Atlanta, GA; July, 2007. Gerberding JL. Health protectionomics: a new science of people, policy, and politics. Public Health Grand Rounds; Washington, DC: George Washington University School of Public Health and Health Services; September 19, 2007. Time 100: the people who shape our world. Time Magazine 2004 April 26. Available at
The Dynamics of Upstream and Downstream: Why is So Hard for the Health System to Work Upstream? Upstream Prevention and Protection -----------------Total 3% Downstream Care and Management ----------------Total 97% Centers for Medicaid and Medicare Services. National health expenditures. Centers for Medicaid and Medicare Services, 2006.
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; Atlanta, GA; 2003. Subcommittee on Labor, Health and Human Services, Education and Related Agencies, United States House of 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
Prerequisite Conditions for Health Peace Income Shelter Stable eco-system Education Sustainable resources Food Social justice and equity Endorsed at five world conferences on health promotion (1986 -2000) World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17 -21, 1986 Ottawa, Ontario, Canada, 1986. Available at
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. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. 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
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. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007.
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
Refining the Hypothesis 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. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
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 it 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 Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Syndemics Prevention Network Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.
Vulnerability is Becoming an Increasingly Prominent Focus of Concern “Vulnerability, the susceptibility to harm, results from…developmental problems, personal incapacities, disadvantaged social status, inadequacy of interpersonal networks and supports, degraded neighborhoods and environments, and the complex interactions of these factors over the life course. ” -- Mechanic & Tanner Syndemics Prevention Network Mechanic D, Tanner J. Vulnerable people, groups, and populations: societal view. Health Affairs 2007; 26(5): 1220 -1230.
Evaluating Dynamic, Democratic Policies How can we learn about the consequences of alternative policies in a system of this kind? Syndemics Prevention Network
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. , 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.
An (Inter) Active Form of Policy Planning/Evaluation System Dynamics is a methodology to… • • Compare results from simulated “What If…” experiments to identify intervention policies that might plausibly alleviate the problem; • Conduct sensitivity analyses to assess areas of uncertainty in the model and guide future research; • Syndemics Convert the map into a computer simulation model, integrating the best information and insight available; • Prevention Network Map the salient forces that contribute to a persistent problem; Convene diverse stakeholders to participate in model-supported “Action Labs, ” which allow participants to discover for themselves the likely consequences of alternative policy scenarios
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
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.
Selected CDC Projects Featuring System Dynamics Modeling (2001 -2007) • 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 Relationships among cost, quality, Fetal and infant morbidity/mortality equity, and health status • Heart Disease and Stroke Preventing and managing multiple • Chronic Illness Dynamics Health and economic scenarios for risks, in context downstream and upstream reforms 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.
Preventing and Managing Risk Factors for Heart Disease and Stroke Modeling the Local Dynamics of Cardiovascular Health Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modeling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease (in press). Syndemics Prevention Network
Contributors Core Design Team • CDC: Michele Casper, Rosanne Farris, Darwin Labarthe, Marilyn Metzler, Bobby Milstein, Diane Orenstein • Austin: Cindy Batcher, Karina Loyo, Ella Pugo, Rick Schwertfeger, Adolfo Valadez, Josh Vest, • NIH: David Abrams, Patty Mabry • Consultants: Jack Homer, Justin Trogdon, Kristina Wile Organizational Sponsors • Austin/Travis County Health and Human Services Department • CDC Division for Heart Disease and Stroke Prevention • CDC Division of Adult and Community Health • CDC Division of Nutrition, Physical Activity, and Obesity • CDC Division of Diabetes Translation • CDC Office on Smoking and Health • CDC NCCDPHP Office of the Director • Indigent Care Collaborative (Austin, TX) • NIH Office of Behavioral and Social Science Research • RTI International • Sustainability Institute • Texas Department of Health Syndemics Prevention Network
Project Purpose Better understand govern trends in cardiovascular health at a local level by modeling the likely consequences of alternative intervention strategies Syndemics Prevention Network
Action Framework for a Comprehensive and Coordinated Public Health Strategy to Prevent Heart Disease and Stroke Syndemics Prevention Network
Crafting Effective Intervention Strategies for Upstream Prevention in Context • • Local social and physical factors may be critical when characterizing the history—and plausible futures—of cardiovascular disease in a given city or region • Syndemics Local conditions affect people’s health status and their responses to perceived problems • Prevention Network Concentrate on “upstream” challenge of minimizing risk, rather than the better understood “downstream” task of post-event care These aspects of local context are difficult to measure and too often excluded when planning and evaluating policies or programs
Project Tasks ü Develop a general causal framework for thinking about CVD risk factors and contextual factors ü Develop a national-level simulation model of CVD risk factors, with projected outcomes based on AHA 2003 estimates and Framingham risk calculator ü Learn about and quantify key contextual factors in Austin as well as local interventions attempted and planned ü Add contextual factors and calibrate the simulation model • Syndemics Prevention Network Evaluate alternative interventions in terms of CV events and costs
Preventing and Managing Risk Factors for CVD Sector Diagram Local capacity for leadership & organizing LOCAL ACTIONS NUTRITION, PHYSICAL ACTIVITY & STRESS LOCAL CONTEXT • Eating & activity options • Smoking policies • Socioeconomic conditions • Environmental policies • Health care options • Support service options • Media and events • Salt intake • Bad fats intake • Fruit/Vegetable intake • Net caloric intake • Physical activity • Chronic stress COSTS (CVD & NON-CVD) ATTRIBUTABLE TO RISK FACTORS RISK FACTOR ONSET, PREVALENCE & CONTROL • Hypertension • High cholesterol • Diabetes • Obesity • Smoking • Secondhand smoke • Air pollution exposure Modified Anderson Risk Calculator UTILIZATION OF SERVICES • Behavioral change • Social support • Mental health • Preventive health ESTIMATED FIRST-TIME FATAL AND NON-FATAL CVD EVENTS • CHD (MI, Angina, Cardiac Arrest) • Stroke • Total CVD (CHD, Stroke, CHF, PAD) Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Core Structure Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Core Structure Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Policy Pathways Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Policy Pathways Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Policy Pathways Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Policy Pathways Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Policy Pathways Syndemics Prevention Network DRAFT: October, 2007
Preventing and Managing Risk Factors for CVD Policy Pathways Syndemics Prevention Network DRAFT: October, 2007
Assembling Available Information Sources U. S. Census & Vital Statistics American Heart Association Relevant Model Parameters • Population • Birth rate • Net immigration rate • Death rate • CVD events • CVD deaths • CVD post-event prevalence • Risk factor prevalences National Health and Nutrition • Fractions diagnosed and undiagnosed Examination Survey • Extent to which "control" reduces CVD risk • Numerous age and gender distinctions Medical Expenditure Panel Survey & • Inpatient hospital costs and workdays lost due to non-CVD National Health Interview Survey consequences of CVD risk factors (Linked) Bureau of Labor Statistics • Working fraction of population • Access to healthy food options • Unhealthy diet • Access to physical activity options Behavioral Risk Factor Surveillance • Inadequate physical activity • Access to regular primary care System • Chronic stress • Trying to lose weight • Trying to quit smoking • Workplaces allowing smoking Syndemics Prevention Network
Assembling Available Information Sources Professional Literature Austin Team Questionnaire Syndemics Prevention Network Relevant Model Parameters • Anderson risk calculator • Prevalence ratios relating obesity with BP, cholesterol, and diabetes • Relative risks from inadequate PA for obesity, diabetes, and high BP • Smoking quit rates • Becoming non-obese rates • PAD prevalence and deaths • Average US air pollution level • Hours spent outdoors per day • Fraction of nonsmokers living with smokers • Effect of smoking quit services on quit rate • Relative risk for CVD from secondhand smoke • Relative risk for CVD from air pollution • Impact of smoking on obesity • Value per lost workday • Direct and indirect costs of CVD events • Access to local weight loss, mental health, and smoking quit services • Use of local primary care, weight loss, mental health, and smoking quit services • Impact of mental health services on stress • Impact of local social marketing on diet, PA, smoking • Impact of local weight loss services on becoming non-obese • Impact of primary care on diagnosis and control of high BP, cholesterol, diabetes • Relative risks from inadequate PA for high cholesterol, stress • Relative risks from chronic stress for high BP, high cholesterol, smoking initiation, quits, obesity • Relative risks from poor diet for high BP, high cholesterol, obesity
Developing a Base Case or “Status Quo” Scenario Assumptions for Input Time Series through 2040 1 -Year Costs of All CV & RF Complications per pre. CVD Popn dollars/(Year*person) 800 • – Assume no further changes in contextual factors affecting risk factor prevalences 600 – Any changes in prevalences after 2000 are due to “bathtub” adjustment process and population aging 400 200 0 1990 A plausible and straightforward scenario No Further Changes in Drivers 1995 2000 2005 2010 2015 2020 2025 2030 2035 – Provides an easily-understood basis for comparisons 2040 Time (Year) • Result: Past trends continue after 2000, but decelerate and level off – Increasing obesity, high BP, and diabetes – Decreasing smoking – High cholesterol mixed bag, flat overall Syndemics Prevention Network
Some Examples of Historical Reproduction Obese Fraction of Total Pre-CVD Population Diabetes Fraction of Total Pre-CVD Population High BP Fraction of Total Pre-CVD Population Smoking Fraction of Total Pre-CVD Population High Cholesterol Fraction of Total Pre-CVD Population Syndemics Prevention Network
Exploring “What If…” Scenarios CVD Risk Factors Directly Affected Policy Interventions Increase (or Decrease)… High Blood Pressure High cholesterol Diabetes Smoking 1 & equivalent Obesity Access to primary care 2 √ √ √ Effectiveness of primary care √ √ √ Access to smoking quit services √ Anti-tobacco policy √ Clean indoor air policies √ Air pollution exposure √ Access to weight loss/maintenance services √ Access to healthy food options √ √ √ Access to physical activity options √ √ Sources of chronic stress (poverty, crime, discrimination) √ √ 3 Access to mental health services 4 √ √ 3 Marketing healthy behaviors 5 √ √ √ Marketing health/social services 6 √ √ √ Syndemics Prevention Network 1 Reductions in smoking may lead to some increase in eating and obesity; 2 Primary care improves diagnosis and control of affected conditions; 3 Due to stress-eating; 4 Affects chronic stress; 5 Affects nutrition, PA, and smoking; 6 Affects primary care as well as services for weight loss/maintenance, smoking cessation, and mental health
Prototype Simulation Scenarios Tests of Extreme Conditions 1 -Year Costs of All Cardiovascular Events & Risk Factor Complications Per Capita Among the pre-CVD Population Dollars/(Year*person) 700 “All models are wrong, some are useful. ” 625 -- George Box 550 475 400 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 Base Primary Care Access 1 Primary Care Effectiveness 1 Diet & PA Access 1 + Social Marketing 1 Access + Marketing + Effective Care Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002; 18(4): 501 -531. Available at
Simulations for Learning in Dynamic Systems Multi-stakeholder Dialogue Dynamic Hypothesis (Causal Structure) Plausible Futures (Policy Experiments) 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.
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 Problems Among People in Places Over Time 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
Becoming a Professional Often Implies Standing Outside of the Public “The challenge of involving the community is especially difficult if one has been trained, as I have been trained, to be an arrogant, elitist prima donna. I am the ‘expert, ’ after all, and I help people by sharing my expertise. ” -- Len Syme Innovators in higher education tend to view professions as “public crafts” and emphasize the democratic skills of “citizen-professionals” Syme SL. Social determinants of health: the community as an empowered partner. Preventing Chronic Disease 2004: 1(1) Accessed December 15, 2003. Available from: http: //www. cdc. gov/pcd/issues/2004/jan/syme. htm Syndemics Prevention Network Boyte HC. Professions as public crafts. Wingspread Conference on New Information Commons; Racine, WI: Center for Democracy and Citizenship; 2000. Available at
Growth of Citizen Actors “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
What Exactly is Public Work? Public work is sustained, visible, serious effort by a diverse mix of ordinary people that creates things of lasting civic or public significance. Mitchell Siporin. Jane Addams memorial. Illinois Federal Art Project, WPA, 1936. Fine Arts Collection, General Services Administration. Syndemics Prevention Network Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at
CDC’s Strength Lies in Wayfinding for Health Through Public Work • • Leadership for system change, both upstream and down, involves inspiring (or confronting) others to establish safer, healthier conditions in their own spheres of influence • At the same time, CDC is among the most trusted sources for defining which conditions are safer and healthier, and for charting progress (past and plausible futures) • Syndemics The agency’s reputation also stems from a widespread perception that CDC staff are working to protect us all: that it is a people’s institution • Prevention Network CDC’s credibility and effectiveness rest on more than scientific excellence These separate aspects of navigation— directing change and charting progress— are easily confused Harris Interactive. CDC, FAA, NIH, FDA, FBI and USDA get the highest ratings of thirteen federal government agencies. Rochester, NY: Harris Polls; February 7, 2007.
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
What’s on the Horizon for System Science & Health? 2007 ü Extramural funding for methodology and technology (NIH Roadmap) ü Symposia series on system science and health (NIH/OBSSR and CDC/SPN; ~6, 000 participants) ü Conference on complexity approaches to population health (Univ of Michigan; ~250 participants) ü NIH monograph, “Greater Than the Sum” • CDC monograph, “Hygeia’s Constellation” • CDC to hire directors for preparedness modeling and public health systems research • Concept mapping of public health policy resistance (NIH/OBSSR and CDC/SPN) • Historical examples of health system transformation (CDC Public Health Practice Council) • Methodology to support CDC’s focus on “health protection…health equity” (Price. Waterhouse. Coopers) 2008 • Summer training institute for system science and health (NIH/OBSSR and CDC/SPN) 2009 • Syndemics Prevention Network Extramural funding for “Health System Change” (NIH and CDC? )
For Further Information • CDC Syndemics Prevention Network • NIH/CDC Symposia on System Science and Health • Recommended Reading http: //www. cdc. gov/syndemics http: //obssr. od. nih. gov/Content/Lectures+and+Seminars/Systems_Symposia_Series/SEMINARS. htm – AJPH theme issue on systems thinking and modeling (March, 2006) http: //www. ajph. org/content/vol 96/issue 3/ • Sterman JD. Learning from evidence in a complex world. AJPH 2006; 96(3): 505 -514. • Midgley G. Systemic intervention for public health. AJPH 2006; 96(3): 466 -472. • Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. AJPH 2006; 96(3): 452 -458. – Sterman JD. A skeptic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209 -229. http: //web. mit. edu/jsterman/www/Skeptic%27 s_Guide. html – Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. http: //www. sustainabilityinstitute. org/pubs/Leverage_Points. pdf – Meadows DH, Robinson JM. The electronic oracle: computer models and social decisions. System Dynamics Review 2002; 18(2): 271 -308. Syndemics Prevention Network
EXTRAS Syndemics Prevention Network
Framework for Program Evaluation “Both a synthesis of existing evaluation practices and a standard for further improvement. ” Left Unexamined… • • Democratic aspects of public health work (e. g. , alignment among multiple actors, including those who are not health professionals—or professionals at all—and those who may be pursuing other goals) • Prevention Network Dynamic aspects of program effectiveness (e. g. , better-before-worse patterns of change) • Syndemics Singular “program” as the unit of inquiry (N=1 organizational depth) Evaluative aspects of planning and policy development Milstein B, Wetterall S, CDC Evaluation Working Group. Framework for program evaluation in public health. MMWR Recommendations and Reports 1999; 48(RR-11): 1 -40. Available at
Revisiting the Framework “Steps in the framework are starting points for tailoring an evaluation to a particular public health effort at a particular time. ” Simulation Modeling Offers • • An avenue for experimentation without comparison/control groups and visceral learning • Ability to track interrelated indicators (both states and rates) • An emphasis on pragmatism (learning through action) • Prevention Network A larger conception of the “program” context in its policy context • Syndemics Support for multi-stakeholder dialogue A focus on the evaluative aspects of planning and policy development Milstein B, Wetterall S, CDC Evaluation Working Group. Framework for program evaluation in public health. MMWR Recommendations and Reports 1999; 48(RR-11): 1 -40. Available at