Syndemics

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Beyond Methodolgoical TechniqueSystems Science in Service of Social Change

Bobby MilsteinInstitute on Systems Science and Health

Ann Arbor, MI May 3-8, 2009

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Troubling Extremes

Over-reliance on Models Under-reliance on Models

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Imperatives for Protecting Health

Gerberding JL. Protecting health: the new research imperative. Journal of the American Medical Association 2005;294(11):1403-1406.

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

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A Growing Portfolio of CDC Efforts areIncorporating System Sciences (e.g., SNA, SD, ABM)

• Infection dynamicsSmallpox, anthrax, HIV, STD, TB, polio, SARS, influenza, etc.

• Chronic diseases and risksDiabetes, obesity, hypertension, cardiovascular disease, oral health, tobacco, diet, physical activity, stress, alcohol, sleep, etc.

• Environmental healthAir, water, soil, heat, climate change, etc.

• PreparednessBiological, radiological, chemical, environmental, etc.

• Violence and InjuryChild maltreatment, sexual assault, etc.

• Grantmaking ScenariosTiming and sequence of outside assistance

• Upstream-Downstream EffortBalancing disease treatment with prevention/protection

• Health System PerformanceRelationships among cost, quality, equity, and health status

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Changing (and Accumulating) Views of Population Health

What Accounts for Poor Population Health?

• God’s will

• Humors, miasma, ether

• Poor living conditions, immorality (e.g., sanitation)

• Single disease, single cause (e.g., germ theory)

• Single disease, multiple causes (e.g., heart disease)

• Single cause, multiple diseases (e.g., tobacco)

• Multiple causes, multiple diseases (but no feedback dynamics) (e.g., multi-causality)

• Dynamic feedback among afflictions, living conditions, and public strength (e.g., syndemic orientation)

1880

1950

1960

1980

2000

1840

Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006.

Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

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Incorporating a Systems Orientation Into Public Health Work

PUBLIC HEALTH WORK

InnovativeHealth

Ventures

UNDERSTANDING CHANGESystems Science

• 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)?

SETTING DIRECTIONPublic Health

What are health leaderstrying to accomplish?

GOVERNING MOVEMENTSocial Navigation

Directing Change

Charting Progress

• Who does the work?• By what means?• According to whose values?

• How are conditions changing?• In which directions?

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Syndemic Orientation

Expanding Public Health Science“Public health imagination involves using science to expand the

boundaries of what is possible.”

-- Michael Resnick

EpidemicOrientation

Problems/Opportunities

Among People in

PlacesOver Time

BoundaryCritique

Governing Dynamics

Ca

us

al

Ma

pp

ing

Plausible Futures

DynamicModeling

Navigational Freedoms

De

mo

cra

tic

Pu

bli

c W

ork

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Syndemic Orientation

Network View Dynamic View

Navigational View

Aligning Concepts and Methods

X Y

Connections Leverage Public Work, Civic Agency

Proximity Data Causal Data Directional Data

What links to what? What influences what? Where are we going?

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A Model Is…An inexact representation of the real thing

They help us understand, explain, anticipate, and make decisions

“All models are wrong, some are useful.”

-- George Box

“All models are wrong, some are useful.”

-- George Box

Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at <http://web.mit.edu/jsterman/www/All_Models.html>

Sterman J. A sketpic'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%27s_Guide.html>

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Boundary Judgments(System of Reference)

Observations(Facts)

Evaluations(Values)

Ulrich W. Boundary critique. In: Daellenbach HG, Flood RL, editors. The Informed Student Guide to Management Science. London: Thomson; 2002. p. 41-42. <http://www.geocities.com/csh_home/downloads/ulrich_2002a.pdf>.

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

Midgley G. The sacred and profane in critical systems thinking. Systems Practice 1992;5:5-16.

Boundary CritiqueCreating 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

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Boundary CritiqueEqualizing Experts and Ordinary Citizens

• “Professional expertise does not protect against the need for making boundary judgements…nor does it provide an objective basis for defining boundary judgements. It’s exactly the other way round: boundary judgements stand for the inevitable selectivity and thus partiality of our propositions.

• It follows that experts cannot justify their boundary judgements (as against those of ordinary citizens) by referring to an advantage of theoretical knowledge and expertise.

• When it comes to the problem of boundary judgements, experts have no natural advantage of competence over lay people.”

Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268.

-- Werner Ulrich

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Defining Keywords

Crick BR. In defense of politics. 4th ed Chicago, IL: University of Chicago Press, 1993.

Boyte HC. Everyday politics: reconnecting citizens and public life. Philadelphia, PA: University of Pennsylvania Press, 2004.

• PartisanFervent, sometimes militant support for a party, cause, faction, person, or idea, from Middle French, part, “faction”

• PoliticalThe action of diverse people negotiating their differences for common governance, from the Greek, politikos, “of the citizen”

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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 Critique

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Conversations Around the Model are Critical

• What measures of improvement ought to be included?

• What else is missing?

• Who else is missing?

• What would be helpful to you?

Smoking

Obesity

Secondhandsmoke

Healthinessof diet

Extent ofphysical activity

Psychosocialstress

Diagnosisand control

First-time CVevents and

deaths

Access to and marketingof smoking quit products

and services

Access to andmarketing of mental

health services

Sources ofstress

Access to andmarketing of healthy

food options

Access to andmarketing of physical

activity options

Access to andmarketing of weight

loss services

Access to andmarketing ofprimary care

Particulate airpollution

Utilization ofquality primary

care

Tobacco taxes andsales/marketing

regulations

Smoking bans atwork and public

places

Junk food taxes andsales/marketing

regulations

Downwardtrend in CV

event fatality

Quality of primarycare provision

Chronic Disorders

Costs from CV and other riskfactor complications and from

utilization of services

Anti-smokingsocial marketing

High BP

Highcholesterol

Diabetes

Air pollutioncontrol regulations

Populationaging

SYSTEMDYNAMICS MODEL

Other chronic disease

endpoints

Downstreaminterventions

and costs

Local implementationopportunitiesLocal

implementationstrengths

and success

Political will

STRATEGICDIALOGUE

Implementationactions and costs

Health inequities

Local leadershipcapacity

Ability to engage all

stakeholders

Borderline conditions

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Navigating Change in Dynamic and Democratic Systems

Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000.

Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Multi-stakeholder

Interactions

Dynamic Hypothesis (Causal Structure)

X Y

Plausible Futures (Policy Experiments)

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“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

Beware of Superficial Understanding

Chambers ET, Cowan MA. Roots for radicals. New York: Continuum, 2003., p. 65.

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Loose groupings of interested individuals don’t have a prayer of addressing major

crises–housing, crime, schools, jobs, and others. Each crisis is, at bottom, a power

crisis. The power of the mob, the power of drug lords, the power of corrupt borough

machines, and the inertia of the police bureaucracy could only be challenged by

another, deeper institutional power.

-- Michael Gecan

Power Has to be Organized

Gecan M. Going public. Boston: Beacon Press, 2002.

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Is Anyone Really an Outsider?

Boyte HC. Doctoral education for the 21st century: reframing scholarship in mass communications. Civic Engagement News 2004;5.

Outside Expert Citizen Actor

Focus • Efficiency of means • Ask both why and how

Discourse • Technical • Political (non-partisan)

Stance • Seeing from discipline • From the world

Goal • Fix problem• Create values• Develop capacities

Philosophy • Positivism • Pragmatism

Key actor(s) • Expert • Citizens (each w/ own expertise)

Skills • Disaggregation, analysis • Integration, anticipation, action

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Innovation, Pragmatism, and the Promise of “What If…” Thinking

Shook J. The pragmatism cybrary. 2006. Available at <http://www.pragmatism.org/>.

Addams J. Democracy and social ethics. Urbana, IL: University of Illinois Press, 2002.

West C. The American evasion of philosophy: a genealogy of pragmatism. Madison, WI: University of Wisconsin Press, 1989.

"Grant an idea or belief to be true…what concrete difference will its being true make in anyone's actual life?

-- William James

Pragmatism• Begins with a response to a perplexity or injustice

in the world• Learning through action and reflection

(even simulated action can be illuminating)• Asks, “How does this work make a difference?”

Positivism • Begins with a theory about the world• Learning through observation and falsification• Asks, “Is this theory true?”

These are conceptual, methodological, and moral orientations, which shape how we think, how we act, how we learn, and what we value