syndemics and the interface between public health, systems science, and social navigation bobby...
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Syndemics and the Interface Between Public Health, Systems Science, and
Social Navigation
Syndemics and the Interface Between Public Health, Systems Science, and
Social Navigation
Bobby Milstein Mid-America Regional Public Health Leadership Institute
April 7, 2006Indianapolis, IN
Bobby Milstein Mid-America Regional Public Health Leadership Institute
April 7, 2006Indianapolis, IN
Bobby Milstein
Syndemics Prevention NetworkCenters for Disease Control and Prevention
[email protected]://www.cdc.gov/syndemics
Bobby Milstein
Syndemics Prevention NetworkCenters for Disease Control and Prevention
[email protected]://www.cdc.gov/syndemics
“Let me assure you, we will survive any
crisis that involves funding, political
support, popularity, or cyclic trends,
but we can't survive the internal crisis,
if we become provincial, focus totally
on the short term, or if we lose our
philosophy of social justice.”
“Let me assure you, we will survive any
crisis that involves funding, political
support, popularity, or cyclic trends,
but we can't survive the internal crisis,
if we become provincial, focus totally
on the short term, or if we lose our
philosophy of social justice.”
-- William Foege-- William Foege
Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.
What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice?
What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice?
What approaches to public health work may help us to recognize and overcome these pitfalls?
What approaches to public health work may help us to recognize and overcome these pitfalls?
What single word best conveys the message of this report?
What single word best conveys the message of this report?
Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988
Diseases of DisarrayDiseases of Disarray
Hardening of the categories
Tension headache between treatment and prevention
Hypocommitment to training
Cultural incompetence
Political phobia
Input obsession
Hardening of the categories
Tension headache between treatment and prevention
Hypocommitment to training
Cultural incompetence
Political phobia
Input obsession
Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 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.
New Word for a Familiar PhenomenonNew Word for a Familiar Phenomenon
Singer M, Snipes C. Generations of suffering: experiences of a treatment program for substance abuse during pregnancy. Journal of Health Care for the Poor and Underserved 1992;3(1):222-34.
Singer M. 1994. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Social Science and Medicine 39(7): 931-948.
Singer M. 1996. A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology 24(2): 99-110.
Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 2003;17(4):423-441.
“We have introduced the term ‘syndemic’ to refer to the set of synergistic
or intertwined and mutually enhancing health and social problems facing
the urban poor. Violence, substance abuse, and AIDS, in this sense, are not
concurrent in that they are not completely separable phenomena.”
“We have introduced the term ‘syndemic’ to refer to the set of synergistic
or intertwined and mutually enhancing health and social problems facing
the urban poor. Violence, substance abuse, and AIDS, in this sense, are not
concurrent in that they are not completely separable phenomena.”
-- Merrill Singer-- Merrill Singer
What was Singer doing?
What are the implications for public health work?
What methodologies support this perspective (scientifically, politically, morally)?
What effects do these ways of thinking and acting have in the world?
What was Singer doing?
What are the implications for public health work?
What methodologies support this perspective (scientifically, politically, morally)?
What effects do these ways of thinking and acting have in the world?
What Does it Mean to Approach Public Health Work from a Syndemic Orientation?
What Does it Mean to Approach Public Health Work from a Syndemic Orientation?
Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. <http://www.cdc.gov/syndemics>.
Ongoing study of innovations in public health work
Member network includes
419 individuals
280 organizations
19 countries
Ongoing study of innovations in public health work
Member network includes
419 individuals
280 organizations
19 countries
Starting PremisesStarting Premises
Public health work has changed significantly since its formalization in the 19th Century, and even today it is poised for further transformation
It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match
We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, and what we value
Public health work has changed significantly since its formalization in the 19th Century, and even today it is poised for further transformation
It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match
We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, and what we value
Plan for TodayPlan for Today
Explore the meaning and implications of a syndemic orientation
Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work
Illustrate how system dynamics maps and simulation models can support innovative thinking and action
Explore the meaning and implications of a syndemic orientation
Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work
Illustrate how system dynamics maps and simulation models can support innovative thinking and action
Epi·demic Epi·demic The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people
Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“
Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people
Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“
Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work
Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.
“Public death was first recognized as a matter of civilized concern
in the nineteenth century, when some public health workers
decided that untimely death was a question between men and
society, not between men and God….Since then, and for that
reason, millions of lives have been saved….The pioneers of public
health did not change nature, or men, but adjusted the active
relationship of men to certain aspects of nature so that the
relationship became one of watchful and healthy respect.
“Public death was first recognized as a matter of civilized concern
in the nineteenth century, when some public health workers
decided that untimely death was a question between men and
society, not between men and God….Since then, and for that
reason, millions of lives have been saved….The pioneers of public
health did not change nature, or men, but adjusted the active
relationship of men to certain aspects of nature so that the
relationship became one of watchful and healthy respect.
Public Health Began as Public WorkPublic Health Began as Public Work
-- Gil Elliot-- Gil Elliot
Syn·demic Syn·demic
The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena
It acknowledges relationships and signals a commitment to studying health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways
The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena
It acknowledges relationships and signals a commitment to studying health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways
Confounding
Connecting*
Synergism
Syndemic
Events
Systems
Co-occurring
* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping
Changing (and Accumulating) Ideas in Causal Theory
What accounts for poor population health?
Changing (and Accumulating) Ideas in Causal Theory
What accounts for poor population health?
God’s will
Humors, miasma, ether
Poor living conditions, immorality (sanitation)
Single disease, single cause (germ theory)
Single disease, multiple causes (heart disease)
Single cause, multiple diseases (tobacco)
Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)
Dynamic feedback among afflictions, living conditions, and public strength (syndemic)
God’s will
Humors, miasma, ether
Poor living conditions, immorality (sanitation)
Single disease, single cause (germ theory)
Single disease, multiple causes (heart disease)
Single cause, multiple diseases (tobacco)
Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology)
Dynamic feedback among afflictions, living conditions, and public strength (syndemic)
1880
1950
1960
1980
2000
1840
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Seeing SyndemicsSeeing Syndemics
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
Placing Health in a Wider Set of Relationships
Placing Health in a Wider Set of Relationships
Health
LivingConditions
PublicStrength
A syndemic orientation is one of a few approaches that includes within it our power to respond
A syndemic orientation is one of a few approaches that includes within it our power to respond
A Philosophy of MeansA Philosophy of Means
“Social and political theory
have neglected the central
question of means, and,
therefore, the problem of
inevitable conflict.”
“Social and political theory
have neglected the central
question of means, and,
therefore, the problem of
inevitable conflict.”
-- Joan Bondurant-- Joan Bondurant
Bondurant JV. Conquest of violence: the Gandhian philosophy of conflict. New rev. ed. Princeton N J: Princeton University Press, 1988.
Toward a Complementary Science of Relationships
Toward a Complementary Science of Relationships
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses
Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
Questioning the Character of Public Health WorkQuestioning the Character of Public Health WorkPUBLIC HEALTH WORK
InnovativeHealth
Ventures
SYSTEMS THINKING & MODELING (understanding change)
• What causes population health problems?
• How are efforts to protect the public’s health organized?
• How and when do health systems change (or resist change)?
PUBLIC HEALTH(setting direction)
What are health leaderstrying to accomplish?
SOCIAL NAVIGATION(governing movement)
Directing Change
Charting Progress
• Who does the work?• By what means?• According to whose values?
• How are conditions changing?• In which directions?
Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004.
Syndemic OrientationWorking Definition
Syndemic OrientationWorking Definition
A way of thinking about public health work that focuses on connections among
health-related problems, considers those connections when developing
health policies, and aligns with other avenues of social change to assure the
conditions in which all people can be healthy
A way of thinking about public health work that focuses on connections among
health-related problems, considers those connections when developing
health policies, and aligns with other avenues of social change to assure the
conditions in which all people can be healthy
Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense
Incorporates 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.
Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense
Incorporates 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.
Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation
System Dynamics
SocialNavigation
POLICYDEVELOPMENT
ASSESSMENT
ASSURANCE
NetworkAnalysis
CategoricalOrientationSyndemic
Orientation
“Solutions” CanCreate New Problems
“Solutions” CanCreate New Problems
Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904.
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
Many Systems Exhibit Policy ResistanceMany Systems Exhibit Policy Resistance
Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35.
Pear R. Health spending rises to record 15% of economy. The New York Times 2004 January 9.
Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.
“At least six times since the
Depression, the United States has
tried and failed to enact a national
health insurance program.”
“At least six times since the
Depression, the United States has
tried and failed to enact a national
health insurance program.”
-- Lee & Paxman-- Lee & Paxman
“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”
“The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.”
-- Meadows, Richardson, Bruckman-- Meadows, Richardson, Bruckman
Flaws in Previous Attempts at Health Reform in AmericaFlaws in Previous Attempts at Health Reform in America
Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999.
Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at <http://www.cpn.org/topics/health/healthquestion.html>.
Piecemeal approaches
Comprehensive strategies that are opposed by special interests
Assumption that healthcare dynamics are separate from other areas of public concern
Conventional analytic methods make it difficult to
Observe the health system as a large, dynamic enterprise
Craft high-leverage strategies that can overcome policy resistance
Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)
Piecemeal approaches
Comprehensive strategies that are opposed by special interests
Assumption that healthcare dynamics are separate from other areas of public concern
Conventional analytic methods make it difficult to
Observe the health system as a large, dynamic enterprise
Craft high-leverage strategies that can overcome policy resistance
Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be produced)
Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521.
How Many Triangles Do You See?How Many Triangles Do You See?
Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf
Boundary CritiqueBoundary Critique
Misleading Framing AssumptionsMisleading Framing Assumptions
Focus on the events
Everything that happens must have a cause
That cause must be close in time and space
Instantaneous impacts
Causality runs one-way
Independence
Impacts are linear and constant
Stepwise progress will lead to system-wide improvement
Focus on the events
Everything that happens must have a cause
That cause must be close in time and space
Instantaneous impacts
Causality runs one-way
Independence
Impacts are linear and constant
Stepwise progress will lead to system-wide improvement
Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.
These assumptions overlook non-local forces of change, such as feedback and delay
These assumptions overlook non-local forces of change, such as feedback and delay
What causes the behaviors we observe?What causes the behaviors we observe?
System-as-CauseSystem-as-Cause
“When we attribute behavior to
people rather than system structure
the focus of management becomes
scapegoating and blame rather than
the design of organizations in which
ordinary people can achieve
extraordinary results.”
“When we attribute behavior to
people rather than system structure
the focus of management becomes
scapegoating and blame rather than
the design of organizations in which
ordinary people can achieve
extraordinary results.”
-- John Sterman-- John Sterman
Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.
“The tendency to blame other people instead of the system is so strong
that psychologists call it the fundamental attribution error.”
“The tendency to blame other people instead of the system is so strong
that psychologists call it the fundamental attribution error.”
Beyond ScapegoatingBeyond Scapegoating
A Very Particular DistanceA Very Particular Distance
Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.
“The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned
with the action of a single individual, but not so far away
as to be ignorant of the internal pressures in the system.”
-- George Richardson
“The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned
with the action of a single individual, but not so far away
as to be ignorant of the internal pressures in the system.”
-- George Richardson
“A symbolic instrument made of a number of methods and techniques
borrowed from very different disciplines…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.”
“A symbolic instrument made of a number of methods and techniques
borrowed from very different disciplines…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.”
Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html
-- Joèel de Rosnay-- Joèel de Rosnay
Looking Through the MacroscopeLooking Through the Macroscope
What processes or phenomena in your work
might we need a macroscope to see?
What processes or phenomena in your work
might we need a macroscope to see?
Time Series ModelsDescribe trends
Multivariate Stat Models
Identify historical trend drivers and correlates
Patterns
Structure
Events
Increasing:
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights
Increasing:
• Depth of causal theory
• Degrees of uncertainty
• Robustness for longer-term projection
• Value for developing policy insights
Dynamic Models
Anticipate future trends, and find policies that maximize chances
of a desirable path
Tools for Policy AnalysisTools for Policy Analysis
Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003.
TertiaryPrevention
SecondaryPrevention
PrimaryPrevention
TargetedProtection
Society's HealthResponse
Demand forresponse
PublicWork
SaferHealthierPeople Becoming
vulnerable
Becoming saferand healthier
VulnerablePeople Becoming
afflicted
Afflictedwithout
Complications Developingcomplications
Afflicted withComplications
Dying fromcomplications
Health System DynamicsHealth System Dynamics
Adverse LivingConditions
GeneralProtection
Understanding Health as Public WorkUnderstanding Health as Public Work
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
Becoming saferand healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
Demand forresponse
GeneralProtection
TargetedProtection
PrimaryPrevention
SecondaryPrevention
TertiaryPrevention
-
Public Work-
Vulnerable andAfflicted People
Fraction of Adversity,Vulnerability and AfflictionBorne by Disadvantaged
Sub-Groups (Inequity)
PublicStrength
-
Citizen Involvementin Public Life
Social Division
World of Providing…
• Health Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access
Medical and Public Health Policy
MANAGEMENT OFRISKS AND DISEASES
World of Transforming…
• Deprivation• Dependency• Violence• Discrimination• Environmental decay• Stress• Insecurity
By Strengthening…
• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom
Healthy Public Policy & Public Work
DEMOCRATIC SELF-GOVERNANCE
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
Becoming safer
and healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
Demand forresponse
GeneralProtection
TargetedProtection
PrimaryPrevention
SecondaryPrevention
TertiaryPrevention
PublicWork
Balancing Two Areas of EmphasisBalancing Two Areas of Emphasis
Testing Dynamic HypothesesTesting Dynamic Hypotheses
-- How can we learn about the consequences of actions in a system of this kind?-- Could the behavior of this system be analyzed using conventional epidemoiological methods (e.g., logistic or multi-level regression)?
SaferHealthierPeople
VulnerablePeople
Afflictedwithout
Complications
Afflicted withComplicationsBecoming
vulnerable
Becoming saferand healthier
Becomingafflicted
Developingcomplications
Dying fromcomplications
Adverse LivingConditions
Society's HealthResponse
Demand forresponse
GeneralProtection
TargetedProtection
PrimaryPrevention
SecondaryPrevention
TertiaryPrevention
-
Public Work-
Vulnerable andAfflicted People
Fraction of Adversity,Vulnerability and AfflictionBorne by Disadvantaged
Sub-Groups (Inequity)
PublicStrength
-
Citizen Involvementin Public Life
Social Division
Learning In and About Dynamic SystemsLearning In and About Dynamic Systems
Benefits of Simulation/Game-based Learning
Formal means of evaluating options
Experimental control of conditions
Compressed time
Complete, undistorted results
Actions can be stopped or reversed
Visceral engagement and learning
Tests for extreme conditions
Early warning of unintended effects
Opportunity to assemble stronger support
Benefits of Simulation/Game-based Learning
Formal means of evaluating options
Experimental control of conditions
Compressed time
Complete, undistorted results
Actions can be stopped or reversed
Visceral engagement and learning
Tests for extreme conditions
Early warning of unintended effects
Opportunity to assemble stronger support
Complexity Hinders
Generation of evidence (by eroding the conditions for experimentation)
Learning from evidence (by demanding new heuristics for interpretation)
Acting upon evidence (by including the behaviors of other powerful actors)
Complexity Hinders
Generation of evidence (by eroding the conditions for experimentation)
Learning from evidence (by demanding new heuristics for interpretation)
Acting upon evidence (by including the behaviors of other powerful actors)
Sterman JD. Learning from evidence in a complex world. AJPH 2006;96(3):505-514.
Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000.
“The complexity of our models vastly exceeds our ability to understand their implications without simulation."
-- John Sterman
“The complexity of our models vastly exceeds our ability to understand their implications without simulation."
-- John Sterman
Transforming the Future of Diabetes…Transforming the Future of Diabetes…
"Every new insight into Type 2 diabetes...
makes clear that it can be avoided--and that
the earlier you intervene the better. The real
question is whether we as a society are up to
the challenge...Comprehensive prevention
programs aren't cheap, but the cost of doing
nothing is far greater..."
Gorman C. Why so many of us are getting diabetes: never have doctors known so much about how to prevent or control this disease, yet the epidemic keeps on raging. how you can protect yourself. Time 2003 December 8. Accessed at http://www.time.com/time/covers/1101031208/story.html.
…in an Era of Epidemic Obesity
Re-Directing the Course of ChangeQuestions from System Modeling and Social NavigationRe-Directing the Course of ChangeQuestions from System Modeling and Social Navigation
20202010
Prevalence of Diagnosed Diabetes, US
0
5
10
15
1980 1985 1990 1995 2000
Mill
ion
peop
le
Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.
How?
Why?
Where?
Who?
Simulations for Learning in Dynamic SystemsDiabetes Dynamics in an Era of Epidemic Obesity
Simulations for Learning in Dynamic SystemsDiabetes Dynamics in an Era of Epidemic Obesity
Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.
Behavior Over Time (Experiments)Behavior Over Time (Experiments)Deaths per Population
0.0035
0.003
0.0025
0.002
0.0015
1980 1990 2000 2010 2020 2030 2040 2050
Time (Year)
Blue: Base run; Red: Clinical mgmt up from 66% to 90%;Green: Caloric intake down 4% (99 Kcal/day);Black: Clin mgmt up to 80% & Intake down 2.5% (62 Kcal/day)
Base
Downstream
Upstream
Mixed
Dynamic Hypothesis (Structure)Dynamic Hypothesis (Structure)
Setting Realistic ExpectationsHP 2010 Diabetes Objectives
Setting Realistic ExpectationsHP 2010 Diabetes Objectives
BaselineHP 2010 Target
Percent Change
Reduce Diabetes–related Deaths Among Diagnosed
(5-6)
8.8 per 1,000
7.8 -11%
Increase Diabetes Diagnosis (5-4)
68% 80% +18%
Reduce New Cases of Diabetes
(5-2)
3.5per 1,000
2.5 -29%
Reduce Prevalence of Diagnosed Diabetes
(5-3)
40 per 1,000
25 -38%
U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm
20
30
40
50
60
70
1980 1985 1990 1995 2000 2005 2010
Pe
op
le w
ith
dia
gn
ose
d d
iab
ete
s p
er
1,0
00
Reported Simulated
Status Quo
Meet Detection Objective (5-4)
Meet Onset Objective (5-2)
HP 2010 Objective (5-3)
HP 2000 Objective
History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results
History and Futures for Diabetes PrevalenceReported Trends, HP Objectives, and Simulation Results
A
B
C
D
E
F
G
H
I
The Simple Physics of DiabetesThe Simple Physics of Diabetes
It is impossible for any policy to reduce prevalence
38% by 2010!
People withUndiagnosed
Diabetes
People withDiagnosedDiabetes Dying from Diabetes
Complications
DiagnosedOnset
InitialOnset
People withNormal
GlycemicLevels
As would stepped-up detection effort
Reduced death wouldadd further to prevalence
With a diagnosed onset flow of
1.1 mill/yr
And a death flow of 0.5 mill/yr
(4%/yr rate)
The targeted 29% reduction in diagnosed onset can only
slow the growth in prevalence
“Simulation is a third way of doing science. Like deduction, it
starts with a set of explicit assumptions. But unlike deduction,
it does not prove theorems. Instead, a simulation generates
data that can be analyzed inductively. Unlike typical induction,
however, the simulated data comes from a rigorously specified
set of rules rather than direct measurement of the real world.
While induction can be used to find patterns in data, and
deduction can be used to find consequences of assumptions,
simulation modeling can be used as an aid to intuition.”
“Simulation is a third way of doing science. Like deduction, it
starts with a set of explicit assumptions. But unlike deduction,
it does not prove theorems. Instead, a simulation generates
data that can be analyzed inductively. Unlike typical induction,
however, the simulated data comes from a rigorously specified
set of rules rather than direct measurement of the real world.
While induction can be used to find patterns in data, and
deduction can be used to find consequences of assumptions,
simulation modeling can be used as an aid to intuition.”
-- Robert Axelrod-- Robert Axelrod
Axelrod R. Advancing the art of simulation in the social sciences. In: Conte R, Hegselmann R, Terna P, editors. Simulating Social Phenomena. New York, NY: Springer; 1997. p. 21-40. <http://www.pscs.umich.edu/pub/papers/AdvancingArtofSim.pdf>.
A Third Branch of ScienceA Third Branch of Science
Syndemic Orientation
Enlarging the Scope of Public Health WorkEnlarging the Scope of Public Health Work“Public health imagination involves using science to expand the
boundaries of what is possible.”
-- Michael Resnick
“Public health imagination involves using science to expand the boundaries of what is possible.”
-- Michael Resnick
EpidemicOrientation
People inPlaces
EcologicalThinking
Governing Dynamics
Ca
us
al
Ma
pp
ing
Plausible Futures
DynamicModeling
Navigational Freedoms
De
mo
cra
tic
Pu
bli
c W
ork
“We are as confused as ever, but on a higher
level and about more important things.”
“We are as confused as ever, but on a higher
level and about more important things.”
Humor Consultants, Inc.Humor Consultants, Inc.
To Sum UpTo Sum Up
For Additional Informationhttp://www.cdc.gov/syndemics
Systems ArchetypeSystems Archetype
Fixes That Fail
Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994.Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994.
-
FixProblemSymptom
+
-
UnintendedConsequence
+
Delay+
+
In Public Health VocabularyIn Public Health Vocabulary
Fixes That Fail
Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994.Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994.
+
TargetedResponse
HealthProblem -
-
Exclusions
+
Delay+
+
ExclusionsExclusions
Conceptual
Social
Organizational
Political
Disarray
Disorientation
Disparity & Disconnection
Together, these forces threaten increasing powerlessness of public health work
Scott JC. Seeing like a state: how certain schemes to improve the human condition have failed. New Haven ; London: Yale University Press, 1999.
"Certain forms of knowledge and control require a
narrowing of vision. The great advantage of such
tunnel vision is that it brings into sharp focus
certain limited aspects of an otherwise far more
complex and unwieldy reality. This very
simplification, in turn, makes the phenomenon at
the center of the field of vision more legible and
hence more susceptible to careful measurement
and calculation….making possible a high degree of
schematic knowledge, control, and manipulation."
"Certain forms of knowledge and control require a
narrowing of vision. The great advantage of such
tunnel vision is that it brings into sharp focus
certain limited aspects of an otherwise far more
complex and unwieldy reality. This very
simplification, in turn, makes the phenomenon at
the center of the field of vision more legible and
hence more susceptible to careful measurement
and calculation….making possible a high degree of
schematic knowledge, control, and manipulation."
There is Great Power in Focusing on One Problem at a Time
There is Great Power in Focusing on One Problem at a Time
-- James Scott-- James Scott
0
1,000
2,000
3,000
4,000
5,000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Num
ber o
f Cig
aret
tes
Even the Greatest Gains are FragileEven the Greatest Gains are Fragile
Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.
“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."
“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."
Broad Street, One Year LaterBroad Street, One Year Later
SpecializationA Proven Problem Solving Approach
SpecializationA Proven Problem Solving Approach
Identify disease
Determine causes
Develop and test interventions
Implement programs and policies
Identify disease
Determine causes
Develop and test interventions
Implement programs and policies
Repeat steps 1-4, as necessary!Repeat steps 1-4, as necessary!
Side Effects of SpecializationSide Effects of SpecializationConfusion, inefficiency, organizational disarray
Competition for shared resources
Attention to “local” causes, near in time and space
Neglected feedback (+ and -)
Confounded evaluations
Coercive power dynamics
Priority on a single value, implicitly or explicitly devaluing others
Limited mandate to address context (living conditions) or infrastructure (public strength)
Disappointing track record, especially with regard to inequalities
Confusion, inefficiency, organizational disarray
Competition for shared resources
Attention to “local” causes, near in time and space
Neglected feedback (+ and -)
Confounded evaluations
Coercive power dynamics
Priority on a single value, implicitly or explicitly devaluing others
Limited mandate to address context (living conditions) or infrastructure (public strength)
Disappointing track record, especially with regard to inequalities
A
C
BD
E
A B C D EIssue Organizations
Neighborhood
Dangers of Getting Too SpecificDangers of Getting Too Specific
Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.
Conventional problem solving proliferates problems
Opens a self-reinforcing niche for professional problem solvers
Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)
Conventional problem solving proliferates problems
Opens a self-reinforcing niche for professional problem solvers
Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected)
Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf
Boundary CritiqueBoundary Critique
How have you observed public health work changing?
What is driving those transformations?
Where is the field headed?
How have you observed public health work changing?
What is driving those transformations?
Where is the field headed?
Innovations in Public Health WorkInnovations in Public Health WorkSteps in Public Health Problem Solving Trends and Emerging Priorities
Define the problem
Eliminate health disparities
Preparedness
Avoid activity limitation
Promote life satisfaction
Increase healthy days
Determine the cause
Social determinants of health
Built environment
Adverse childhood experiences
Genetics
Develop and test interventions
Comprehensive community initiatives
Ecological perspectives
Inter-sector collaboration
Health impact assessments
Implement programs and policies
Policy interventions
Community and systems change
Adaptation to local context
Increasing health care access
And scores more….And scores more….
Public health work is becoming more…
Inter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control
Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability
Questioning (evaluative, reflexive, critical, practical)Concerned with creating and protecting values like health, dignity, security, satisfaction, justice, wealth, and freedom in both means and ends
Public health work is becoming more…
Inter-connected (ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control
Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability
Questioning (evaluative, reflexive, critical, practical)Concerned with creating and protecting values like health, dignity, security, satisfaction, justice, wealth, and freedom in both means and ends
A Field in TransitionA Field in Transition
Many other orientations rely on disconnected, singular, and unthinking approaches where means and ends have very different qualities (e.g., security by means of war)
Many other orientations rely on disconnected, singular, and unthinking approaches where means and ends have very different qualities (e.g., security by means of war)
Locating categorical disease programs within a broader system of health protection
Constructing credible knowledge without comparison/control groups
Differentiating questions that focus on attribution versus contribution
Balancing trade-offs between short- and long-term effects
Avoiding the pitfalls of professonalism
Harnessing the power of citizen-led public work
Defining standards and values for judgment
Others…
Locating categorical disease programs within a broader system of health protection
Constructing credible knowledge without comparison/control groups
Differentiating questions that focus on attribution versus contribution
Balancing trade-offs between short- and long-term effects
Avoiding the pitfalls of professonalism
Harnessing the power of citizen-led public work
Defining standards and values for judgment
Others…
Serious Challenges for Planners and EvaluatorsSerious Challenges for Planners and Evaluators
Placing Health in a Wider Set of Relationships
Placing Health in a Wider Set of Relationships
“Model boundaries influence the recognition of feedback and
potential sources of environmental instability.”
-- Jay Forrest
“Model boundaries influence the recognition of feedback and
potential sources of environmental instability.”
-- Jay Forrest
Forrest J. Evolution and behavior of system structure: eight perspectives for examining a complex issue. 22nd International Conference of the System Dynamics Society; Oxford, England; 2004.
A syndemic orientation clarifies the dynamic and democratic character
of public health work
Exploring a Syndemic OrientationExploring a Syndemic OrientationStudy of innovations in public health work, with emphasis on transformations in concepts and methods
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Phase 1 (2001-2003): identify innovations and dilemmas; develop working definitions; explore relevant concepts and methods
Phase 2 (2004-2005): articulate the foundations of a syndemic orientation; work with leaders at the CDC and beyond to stimulate creativity, innovation, and reorient health protection ventures
Study of innovations in public health work, with emphasis on transformations in concepts and methods
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Phase 1 (2001-2003): identify innovations and dilemmas; develop working definitions; explore relevant concepts and methods
Phase 2 (2004-2005): articulate the foundations of a syndemic orientation; work with leaders at the CDC and beyond to stimulate creativity, innovation, and reorient health protection ventures
Health
LivingConditions
Public Strength
Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>
How strong an influence do planned public health actions have on shaping
the conditions for health?
How strong an influence do planned public health actions have on shaping
the conditions for health?
Public Health Goals Are Expanding…and Accumulating
Public Health Goals Are Expanding…and Accumulating
Prevent disease and injury (~1850 -- present)
Promote health and development (1974 -- present)
Assure the conditions in which people can be healthy (1988 -- present)
Prevent disease and injury (~1850 -- present)
Promote health and 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
“The perfection of means and confusion of goals characterizes our age.”
-- Albert Einstein
What does it mean to organize science and society around the goal of assuring healthful conditions?
What does it mean to organize science and society around the goal of assuring healthful conditions?
Goals Have a Nested StructureGoals Have a Nested StructureDisease Prevention
Prevent disease and injury
Disease Prevention
Prevent disease and injury
Imply that prerequisite conditions exist and that most, if not all, disease
prevention programs are effective simultaneously
Imply that prerequisite conditions exist and that most, if not all, disease
prevention programs are effective simultaneously
Health Promotion
Prolong length
Improve quality
Eliminate disparity
Enhance satisfaction
Health Promotion
Prolong length
Improve quality
Eliminate disparity
Enhance satisfaction
Public Health
Assure the conditions for health for all
Public Health
Assure the conditions for health for all
Stepwise or Synergy?Stepwise or Synergy?
0
100
0
100
Percent of Afflictions Under Control*
1850 2000 2100
Forces of change suggest one of these paths:
* For subgroups of the public; no afflictions have been controlled equitably except for smallpox
1950
%
%Year
“The time has come to close the book on infectious diseases. We have basically wiped out the infection in the United States.”
-- Surgeon General William Stewart (1967)
“The time has come to close the book on infectious diseases. We have basically wiped out the infection in the United States.”
-- Surgeon General William Stewart (1967)
Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.
"In problem solving we seek to make something we do not like
go away. In creating, we seek to make what we truly care
about exist… We can get so caught up in reacting to problems
that it is easy to forget what we actually want. Organizations
must do both–resolve day-to-day problems and generate new
results. But if your primary role is to fix problems, individually
or collectively, rather than create something new and
meaningful, it's hard to maintain a sense of purpose, and..it's
difficult to harness the energy, passion, commitment, and
perseverance needed to thrive in challenging times."
"In problem solving we seek to make something we do not like
go away. In creating, we seek to make what we truly care
about exist… We can get so caught up in reacting to problems
that it is easy to forget what we actually want. Organizations
must do both–resolve day-to-day problems and generate new
results. But if your primary role is to fix problems, individually
or collectively, rather than create something new and
meaningful, it's hard to maintain a sense of purpose, and..it's
difficult to harness the energy, passion, commitment, and
perseverance needed to thrive in challenging times."
Solving Problems and Creating ValueSolving Problems and Creating Value
-- Peter Senge-- Peter Senge
Identify place or population
Organize with residents/members to:
Identify afflictions and their relationships
Examine living conditions and why they differ
Devise beneficial system-wide policies
Build power to act
Direct the course of social change to assure the conditions for health for all
Expand to other places/populations, as necessary
Identify place or population
Organize with residents/members to:
Identify afflictions and their relationships
Examine living conditions and why they differ
Devise beneficial system-wide policies
Build power to act
Direct the course of social change to assure the conditions for health for all
Expand to other places/populations, as necessary
Steps in a Syndemic ApproachSteps in a Syndemic Approach
Syndemic Orientation
Network View Systems View
Navigational View
Formalizing an OrientationJoining Concepts and Methods
Formalizing an OrientationJoining Concepts and Methods
X Y
Connections Leverage Directed Public Work
Proximity Data Causal Data Directional Data
What links to what? What influences what? Where are we going?
Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004.
Studying StabilityStudying Stability
Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. Accessed May 23, 2003 at <http://pespmc1.vub.ac.be/MACRBOOK.html>.
“There is no sociology of balance which is interested in the
social problems of a stabilized society…There is no
political science of equilibrium capable of enlightening
us on the means of exercising the democratic choice in a
society where short-term material gain would cease to be
the criterion of political success. ”
-- Joèel deRosnay
“There is no sociology of balance which is interested in the
social problems of a stabilized society…There is no
political science of equilibrium capable of enlightening
us on the means of exercising the democratic choice in a
society where short-term material gain would cease to be
the criterion of political success. ”
-- Joèel deRosnay
Seeking Syn-SolutionsSeeking Syn-Solutions
“If the health consequences of sprawl
represent a ‘syndemic’–a combination
of synergistic epidemics that
contributes to the population burden of
disease–then solutions may also
operate synergistically, ameliorating
several health problems.”
“If the health consequences of sprawl
represent a ‘syndemic’–a combination
of synergistic epidemics that
contributes to the population burden of
disease–then solutions may also
operate synergistically, ameliorating
several health problems.”
-- Howard Frumkin-- Howard Frumkin
Frumkin H. Urban sprawl and public health. Public Health Reports 2002;117(3):201-17.
“When X and Y affect each other, one cannot study the link between
X and Y and, independently, the link between Y and X and predict
how the system will behave. Only the study of the whole
system as a feedback system will lead to correct results."
“When X and Y affect each other, one cannot study the link between
X and Y and, independently, the link between Y and X and predict
how the system will behave. Only the study of the whole
system as a feedback system will lead to correct results."
-- System Dynamics Society-- System Dynamics Society
The Feedback ThoughtThe Feedback Thought
System Dynamics Society. What is system dynamics? System Dynamics Society, 2002. Accessed December 19, 2002 at <http://www.systemdynamics.org/>.
Richardson GP. Feedback thought in social science and systems theory. Philadelphia: University of Pennsylvania Press, 1991.
X Y
What happens if we shift from thinking about the variable-as-cause to the
system-as-cause?
What happens if we shift from thinking about the variable-as-cause to the
system-as-cause?
Argyris C. Actionable knowledge: design causality in the service of consequential theory. Journal of Applied Behavioral Science 1996;32(4):390-408.
Dent E. The interactional model: an alternative to the direct cause and effect construct for mutually causal organizational phenomena. Foundations of Science in press.
Richmond B. The "thinking" in systems thinking: seven essential skills. Waltham, MA: Pegasus Communications, 2000.
Beyond the Probable FutureBeyond the Probable Future
PossibleWhat may happen?
PlausibleWhat could happen?
ProbableWhat will likely happen?
PreferableWhat do we want to have happen?
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
“Most organizations plan around what is most likely. In so doing they reinforce what is, even though they want something very different.”
-- Ciement Bezold
Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation
System Dynamics
SocialNavigation
POLICYDEVELOPMENT
ASSESSMENT
ASSURANCE
NetworkAnalysis
CategoricalOrientationSyndemic
Orientation
Techniques • Storytelling, scenario-based planning• Game-based learning• Simulation experiments• Health impact assessment
Techniques • Leadership/institutional development• Power and interest mapping• Broad-based, multi-issue organizing• Action planning• Public work• Navigational statistics
Techniques • Problem naming• Network analysis• Time-trend analysis• Summary measures
Policy DevelopmentPolicy Development
Explicit model building
Simulated experiments
What if…
What futures are plausible?
Real world action and observation
Explicit model building
Simulated experiments
What if…
What futures are plausible?
Real world action and observation
“The future is not to be predicted, but created.”
-- Arthur C. Clarke
“The future is not to be predicted, but created.”
-- Arthur C. Clarke
Patterns
Events
Analysis Process for Developing Policy
Analysis Process for Developing Policy
Adapted from: Successful Systems, Inc.
IssueIdentification
Variable & Behavior Analysis
Time
IssueIdentification
Variable & Behavior Analysis
Causal Loop Mapping
Understanding Strategy &Policy Implications
Implementing Action Plan
StructureCausal Loop
MappingSimulationModeling
Curve-Fitting Models
Dynamic Models
Curve-Fitting Models
Dynamic Models
Curve-Fitting Models
Dynamic Models
Insight Generating
Capacity
Descriptive Realism
Mode Reproduction
Ability
Transparency
Relevance
Ease of Enrichment
Fertility
Formal Correspondence
with Data
Point Predictive Ability
Source: Randers JR. Elements of the System Dynamics Method. Cambridge Mass: Productivity Press, 1980. p. xx.
Curve-Fitting Models
Dynamic Models
Seeing the Whole SystemSeeing the Whole System
Benefits
Places value on health and protection
Defines operational objectives (and timeframes)
Distinguishes types of work
Identifies needed information
Articulates a research agenda
Benefits
Places value on health and protection
Defines operational objectives (and timeframes)
Distinguishes types of work
Identifies needed information
Articulates a research agenda
Highlights Threats From
Imbalanced efforts
Short-sighted efforts
Adverse living conditions
Insufficient public work
Organizational disarray
Pitfalls of professionalism
Highlights Threats From
Imbalanced efforts
Short-sighted efforts
Adverse living conditions
Insufficient public work
Organizational disarray
Pitfalls of professionalism
Two Policy OrientationsTwo Policy OrientationsHealthy Public Policy Medical and Public Health Policy
Concerned chiefly with assuring healthful conditions
Concerned chiefly with preventing and alleviating affliction
Relies heavily on multiple small-scale local solutions, with low technology
Relies heavily on singular high technology solutions, widely applied
Expands to a broader synthesis, transcending sector boundaries
Confines analyses to the health sector
Future oriented Present oriented
Questions the givens Accepts the givens
Adapted from: Hancock T. Beyond health care: from public health policy to healthy public policy. Can J Public Health 1985;76 Suppl 1:9-11.
Light DW. The rhetorics and realities of community health care: the limits of countervailing powers to meet the health care needs of the twenty-first century. Journal of Health Politics, Policy, and Law 1997;22(1):105-45.
Effective Screening and Care Actually Increase Diagnosed Prevalence
Effective Screening and Care Actually Increase Diagnosed Prevalence
The combination of more detection and decreasing deaths leads to more people living with diagnosed diabetes
The combination of more detection and decreasing deaths leads to more people living with diagnosed diabetes
Diagnosed Diabetes Frac of Adult Population
0.15
0.1125
0.075
0.0375
0
1980 1990 2000 2010 2020 2030 2040 2050Time (Year)
Dx diabetes fraction of adult popn : base fractionDx diabetes fraction of adult popn : 2010down fraction
Diagnosed Diabetes Frac of Adult Population
0.15
0.1125
0.075
0.0375
0
1980 1990 2000 2010 2020 2030 2040 2050Time (Year)
Dx diabetes fraction of adult popn : base fractionDx diabetes fraction of adult popn : 2010down fraction
What Could We Have Been Thinking?What Could We Have Been Thinking?
People withUndiagnosed
Chronic Disease
People withDiagnosed
Chronic Disease Dying fromComplications
DiagnosingDisease
SaferHealthierPeople
Developing Disease(incidence)
Generic Chronic Disease Structure
People withUndiagnosed
Infectious Disease
People withDiagnosed
Infectious Disease Dying fromComplications
DiagnosingDisease
SaferHealthierPeople
Developing Disease(incidence)
Recovering fromDisease
Generic Infectious Disease Structure
Different Modeling Approaches For Different Purposes
Different Modeling Approaches For Different Purposes
Logic Models
(flowcharts, maps or diagrams)
System Dynamics
(causal loop diagrams and simulation models)
Forecasting
Models
Articulate steps between program actions and results
Improve understanding about the possible effects of a policy over time
Focus on patterns of change over time (e.g., long delays, worse before better)
Make accurate forecasts of key variables
Focus on precision of point predictions and confidence intervals
Limits of Logic ModelsLimits of Logic Models
Logic models may look reasonable, but they can’t answer
Where to direct effort?When to act?How much effort will it take?What’s the expected benefit?When to expect change?What is the difference between various approaches?
Such questions can only be answered by experimenting, either through simulation or in the real-world
Logic models may look reasonable, but they can’t answer
Where to direct effort?When to act?How much effort will it take?What’s the expected benefit?When to expect change?What is the difference between various approaches?
Such questions can only be answered by experimenting, either through simulation or in the real-world
Dynamic Models Let Us Search for Policies with the Greatest LeverageDynamic Models Let Us Search for Policies with the Greatest Leverage
Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options:
they provide added foresight
Such models open new avenues for planning and formally evaluating prevention policies
Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options:
they provide added foresight
Such models open new avenues for planning and formally evaluating prevention policies
Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.
0.0035
0.003
0.0025
0.002
0.0015
1980 1990 2000 2010 2020 2030 2040 2050Time (Year)
Diabetes-related death rate per year for adult popnBase
Mgmt90
Cal3
Mgmt85Cal2
0.0035
0.003
0.0025
0.002
0.0015
1980 1990 2000 2010 2020 2030 2040 2050Time (Year)
Diabetes-related death rate per year for adult popnBase
Mgmt90
Cal3
Mgmt85Cal2
Results from four simulation experiments using the Diabetes System Model
Results from four simulation experiments using the Diabetes System Model
Steps for Putting Maps in MotionSteps for Putting Maps in MotionIdentify a persistent problem that exists, in part, due to dynamic complexity (i.e., forces of feedback, delay, non-linearity, etc…)
Develop a preliminary dynamic hypothesis (i.e., what causal forces are at work?)
Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on available data; areas of uncertainty are noted and become the focus for sensitivity analysis)
Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time
Iteratively repeat the process, creating better hypotheses, better models, better policy insight, and more effective action
Identify a persistent problem that exists, in part, due to dynamic complexity (i.e., forces of feedback, delay, non-linearity, etc…)
Develop a preliminary dynamic hypothesis (i.e., what causal forces are at work?)
Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on available data; areas of uncertainty are noted and become the focus for sensitivity analysis)
Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time
Iteratively repeat the process, creating better hypotheses, better models, better policy insight, and more effective action
“Even the best conceptual models can only be tested and improved by relying on the learning feedback through the real world…This feedback is very slow and often rendered ineffective by dynamic complexity, time delays, inadequate and ambiguous feedback, poor reasoning skills, defensive reactions, and the costs of experimentation. In these circumstances simulation becomes the only reliable way to test a hypothesis and evaluate the likely effects of policies."
“Even the best conceptual models can only be tested and improved by relying on the learning feedback through the real world…This feedback is very slow and often rendered ineffective by dynamic complexity, time delays, inadequate and ambiguous feedback, poor reasoning skills, defensive reactions, and the costs of experimentation. In these circumstances simulation becomes the only reliable way to test a hypothesis and evaluate the likely effects of policies."
-- John Sterman-- John Sterman
Why Simulate Proposed Policies?Why Simulate Proposed Policies?
Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
AssuranceAssurance
Assure conditions that expand peoples’ freedoms to live healthfully and develop their creative potential
Powered by democratic public work, including that of citizen-professionals
Navigational perspective, guided by vision and values
Forward orientation
Adapts to constantly changing conditions
Breakdown means-end framing
Assure conditions that expand peoples’ freedoms to live healthfully and develop their creative potential
Powered by democratic public work, including that of citizen-professionals
Navigational perspective, guided by vision and values
Forward orientation
Adapts to constantly changing conditions
Breakdown means-end framing
“The path resounds to our footfall, but do we have it in ourselves to change direction?”
-- Peter Ustinov
“The path resounds to our footfall, but do we have it in ourselves to change direction?”
-- Peter Ustinov
"A bad solution is bad because it acts destructively upon the
larger patterns in which it is contained...because it is formed
in ignorance or disregard of them. A bad solution solves for a
single purpose or goal, such as increased production. And it
is typical of such solutions that they achieve stupendous
increase in production at exorbitant biological and social
costs…Good solutions recognize that they are part of a larger
whole. They solve more than one problem and don't create
new problems. A good solution should not enrich one person
by the distress or impoverishment of another."
"A bad solution is bad because it acts destructively upon the
larger patterns in which it is contained...because it is formed
in ignorance or disregard of them. A bad solution solves for a
single purpose or goal, such as increased production. And it
is typical of such solutions that they achieve stupendous
increase in production at exorbitant biological and social
costs…Good solutions recognize that they are part of a larger
whole. They solve more than one problem and don't create
new problems. A good solution should not enrich one person
by the distress or impoverishment of another."
-- Wendell Berry-- Wendell Berry
Berry W. Solving for pattern. In: The Gift of Good Land. San Francisco: North Point; 1981. p. 134-45.
Solving for PatternSolving for Pattern
A syndemic orientation clarifies the dynamic and democratic character
of public health work
The Syndemics Prevention NetworkThe Syndemics Prevention Network
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Learning within innovative ventures
Comprehensive Community InitiativesPhilanthropy
Legacy InitiativesState Tobacco Settlements
Efforts to Eliminate Health Disparities Government and Philanthropy
Responses to Unjust Conditions Broad-based Citizen Organizations
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Learning within innovative ventures
Comprehensive Community InitiativesPhilanthropy
Legacy InitiativesState Tobacco Settlements
Efforts to Eliminate Health Disparities Government and Philanthropy
Responses to Unjust Conditions Broad-based Citizen Organizations
Health
LivingConditions
PublicStrength
Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
Seeing SyndemicsSeeing Syndemics
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)
The word syndemic signals a special concern for relationships
Mutually reinforcing character of health problems
Connections between health status and living conditions
Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and citizens)
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
Placing Health in a Wider Set of Relationships
Placing Health in a Wider Set of Relationships
Health
LivingConditions
PublicStrength
A syndemic orientation is one of a few approaches that includes within it our power to respond
A syndemic orientation is one of a few approaches that includes within it our power to respond
Working in a New EraWorking in a New Era
“Today’s world, characterized by tremendous
globalization, connectivity, and speed poses
entirely new challenges. We have to be better
prepared to respond to the multiple public
health challenges, including those resulting
from an aging population, global threats of
disease and terrorism, obesity, and epidemic
threats of chronic diseases.”
“Today’s world, characterized by tremendous
globalization, connectivity, and speed poses
entirely new challenges. We have to be better
prepared to respond to the multiple public
health challenges, including those resulting
from an aging population, global threats of
disease and terrorism, obesity, and epidemic
threats of chronic diseases.”
-- Julie Gerberding-- Julie Gerberding
Centers for Disease Control and Prevention. CDC announces new goals and organizational design. Atlanta, GA; May 13, 2004. <http://www.cdc.gov/od/oc/media/pressrel/r040513.htm>.
What is the largest living organism?
What is the largest living organism?
Not Everything Meets the EyeLargest Living Organism
Not Everything Meets the EyeLargest Living Organism
Amos J. Fantastic fungus find: BBC News; August 7, 2000. <http://news.bbc.co.uk/1/hi/sci/tech/869808.stm>.
“You would not look at it and see a huge, looming
mushroom. Armillaria grows and spreads primarily
underground and the sheer bulk of this organism lies in
the earth, out of sight.”
“You would not look at it and see a huge, looming
mushroom. Armillaria grows and spreads primarily
underground and the sheer bulk of this organism lies in
the earth, out of sight.”
-- Jonathan Amos-- Jonathan Amos
A syndemic orientation clarifies the dynamic and democratic character
of public health work
Background on the Syndemics ProjectBackground on the Syndemics Project
Studying innovations in public health work, with emphasis on transformations in concepts and methods
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Phase 1 (2001-2003): identify innovations and dilemmas; develop working definitions; explore relevant concepts and methods
Phase 2 (2004-2006): articulate the foundations of a syndemic orientation; work with leaders at the CDC and beyond to stimulate creativity, innovation, and reorient health protection ventures
Studying innovations in public health work, with emphasis on transformations in concepts and methods
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Phase 1 (2001-2003): identify innovations and dilemmas; develop working definitions; explore relevant concepts and methods
Phase 2 (2004-2006): articulate the foundations of a syndemic orientation; work with leaders at the CDC and beyond to stimulate creativity, innovation, and reorient health protection ventures
Health
LivingConditions
Public Strength
Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
Aspects of a syndemic orientation incorporate twenty-first century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of
adhering to this orientation remain largely unexplored.”
Aspects of a syndemic orientation incorporate twenty-first 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.
But What is a Syndemic Orientation?
But What is a 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.
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.
A syndemic orientation clarifies the dynamic and democratic character
of public health work
Seeing SyndemicsSeeing Syndemics
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Learning within innovative ventures
Comprehensive Community InitiativesPhilanthropy
Legacy InitiativesState Tobacco Settlements
Efforts to Eliminate Health Disparities Government and Philanthropy
Responses to Unjust Conditions Broad-based Citizen Organizations
The word syndemic signals special concern for many kinds of relationships:
mutually reinforcing health problems
health status and living conditions
synergy/fragmentation in the health response system
Learning within innovative ventures
Comprehensive Community InitiativesPhilanthropy
Legacy InitiativesState Tobacco Settlements
Efforts to Eliminate Health Disparities Government and Philanthropy
Responses to Unjust Conditions Broad-based Citizen Organizations
Health
LivingConditions
PublicStrength
Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
“True innovation occurs when things are put together for the first time that had been separate.”
– Arthur Koestler
Toward a Complementary Science of Relationships
Toward a Complementary Science of Relationships
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Protects Population HealthDynamic interaction among multiple problems, problem solvers, and responses
Efforts to Reduce Population Health ProblemsProblem, problem solver, response
Efforts to Organize a System that Protects Population HealthDynamic interaction among multiple problems, problem solvers, and responses
Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
“You think you understand two because you understand one and one. But you must also understand ‘and’.”
-- Sufi Saying
Continues Movement Away From Single-Issue Epidemiology
Continues Movement Away From Single-Issue Epidemiology
Community Health Centers (COPC)Health Systems AgenciesEnvironmental JusticeHealth Care For AllHealthy Cities/Healthy CommunitiesSocial InequalitiesTurning PointPerformance StandardsEcosystem HealthOthers….
Community Health Centers (COPC)Health Systems AgenciesEnvironmental JusticeHealth Care For AllHealthy Cities/Healthy CommunitiesSocial InequalitiesTurning PointPerformance StandardsEcosystem HealthOthers….
Sirianni C, Friedland L. Community health and civic organizing. In: Civic innovation in America: community empowerment, public policy, and the movement for civic renewal. Berkeley: University of California Press; 2001. p. 138-185.
Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93.
Simulations for Learning in Dynamic SystemsThe Problem of Outside Assistance
Simulations for Learning in Dynamic SystemsThe Problem of Outside Assistance
Dynamic Hypothesis (Structure)Dynamic Hypothesis (Structure)
Behavior Over Time (Experiments)Behavior Over Time (Experiments)Affliction
prevalence& burden
Adverseliving
Publicstrength
R1
At-risk fraction
Afflictioncross-impacts
Effort to alleviate andprevent affliction
B1a
Effort to improveliving conditions
B1b
Effort to build public strength
B2
Social disparityR2c
R2b
R2a
R3a
Public work fraction
United efforts
Divided efforts
R3b
Outside assistance toalleviate and prevent
affliction
Outside assistanceto improve living
conditions
Outside assistanceto build public strength
Magnitude ofameliorative efforts
R4a
R4b B3b
B3a
KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop
conditions
12
10
8
6
4
0 2 4 6 8 10 12 14 16 18 20Time (years)
Affliction burden : BasicOptAffliction burden : BasicAF111Affliction burden : BasicLC111Affliction burden : BasicCS111
12
10
8
6
4
0 2 4 6 8 10 12 14 16 18 20Time (years)
Affliction burden : BasicOptAffliction burden : BasicAF111Affliction burden : BasicLC111Affliction burden : BasicCS111
Homer J, Milstein B. Optimal decision making in a dynamic model of poor community health. Proceedings of the 37th Hawaii International Conference on System Science; Big Island, Hawaii; January 5-8, 2004. Available at <http://csdl.computer.org/comp/proceedings/hicss/2004/2056/03/205630085a.pdf>.
Iterative Steps in System Dynamics Simulation Modeling
Iterative Steps in System Dynamics Simulation Modeling
Enact PolicyBuild power and
organize actors to establish chosen policies
Enact PolicyBuild power and
organize actors to establish chosen policies
Learn About Policy Consequences
Test proposed policies, searching for ones that
best govern change
Learn About Policy Consequences
Test proposed policies, searching for ones that
best govern change
Run Simulation Experiments
Compare model’s behavior to expectations and/or data to
build confidence in the model
Run Simulation Experiments
Compare model’s behavior to expectations and/or data to
build confidence in the model
Convert the Map Into a Simulation Model
Formally quantify the hypothesis using allavailable evidence
Convert the Map Into a Simulation Model
Formally quantify the hypothesis using allavailable evidence
Create a Dynamic Hypothesis Identify and map the
main causal forces that create the problem
Create a Dynamic Hypothesis Identify and map the
main causal forces that create the problem
Identify a Persistent Problem Graph its behavior
over time
Identify a Persistent Problem Graph its behavior
over time
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.
Average Number of Adult Unhealthy Days per Month
2
4
6
8
1993 1995 1997 1999 2001
Year
2005 2025 2050
Redirecting the Course of ChangeQuestions from System Dynamics and Social Navigation
Redirecting the Course of ChangeQuestions from System Dynamics and Social Navigation
14% increase
Zack MM, Moriarty DG, Stroup DF, Ford ES, Mokdad AH. Worsening trends in adult health-related quality of life and self-rated health–United States, 1993-2001. Public Health Reports 2004;119(September-October):493-505.
How?Why?
Where?
Who?
Basic Problem Solving OrientationsBasic Problem Solving Orientations
Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Event Oriented View
Problem Results
Goals
Situation
Decision
“Side Effects”
Feedback View
Goals
Environment
Decisions
Goals ofOthers
Actions ofOthers
“Side Effects”
Delay Delay
Delay
Delay
DelayDelay
Delay
Delay
Delay
Delay
Delay
Delay