Possibilities for Better Integrating System Dynamics Into Public Health

Bobby Milstein21st International Conference of the System Dynamics Society

New York, 2003

Seeing Beyond the Probable

PossibleWhat may happen?PlausibleWhat could happen?ProbableWhat will likely happen?PreferableWhat 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.

“Most organizations plan around what is most likely. In so doing they reinforce what is, even though they want something very different.”

-- Ciement Bezold

Smallpox EradicationOur Greatest (Temporary) Victory

A Glimpse Into 2020

Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

Starting Assumptions

Most public health agencies act as if each affliction can be prevented individually by understanding its unique causes and developing targeted interventions

This compartmentalized approach is ingrained in financial structures, problem solving frameworks, statistical models, and criteria for professional prestige

Need A Complementary Science of Relationships

Problem, problem solver, response

Coordination of multiple problems, problem solvers, and responses

Diseases of Disarray

Hardening of the categoriesTension headache between treatment and preventionHypocommitment to trainingCultural incompetencePolitical phobiaInput obsession

Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8.

Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

Spectrum of Prevention

SHORTmonths-years

INTERMEDIATEyears-decades

LONGdecades-centuries

Time Horizon for Observing Effects on Population Health Status*

* Effects on outcomes other than population health status (e.g., risk/protective behaviors, change agents, or system changes) can be observed in shorter time intervals

SECONDARY &TERTIARY

Biological Change

Healing ServicesFocus on Affliction

PRIMARY & SECONDARY

BehavioralChange

Focus on RiskDisease Prevention

INTERGENERATIONAL

Social Change

Focus on ConditionsHealth Promotion

Focus on Capacity for ActionCapacity Building or Empowerment

Infrastructural Change

Public Health Goals Are Accumulating and Becoming More Systemic

Prevent disease and injury (~1850 -- present)

Promote health and human development (1974 -- present)

Assure the conditions in which people can be healthy (1988 -- present)

“The perfection of means and confusion of goals characterizes our age.”

-- Albert Einstein

Virtually Unstoppable Trends in Prevention Science

Systems-oriented

Politically engaged

Philosophically conscious

What Is Not Happening

IntegrationDynamic hypotheses of health states and rates

Testing through simulationSearching for polices that can be effectiveRehearsing policy implementationLearning about dynamic complexity

Brief History of Causal TheoryWhat accounts for poor community health?

God’s will Humors, miasma, etherPoor living conditions, immorality (sanitation)Single disease, single cause (germ theory)Single disease, multiple causes (heart disease)Single cause, multiple diseases (tobacco)Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology) Dynamic feedback among afflictions, living conditions, and community capacity (syndemic)

1880

1950

1960

1980

2000

1840

Cost-effectiveness analysis: simulating patterns of disease dynamics, prevention activities, and resources

Program dynamics: simulating system-wide impacts of comprehensive programs with interacting components

Community dynamics: simulating the mediating effects of local conditions, capabilities, and constraints

Group model building: providing more structure and insight to the participatory planning process

Game-based learning: improving intuition, foresight, commitment, and agility in navigating change

Roles for System Modelingin Public Health