Toward A Syndemic View of Urban Health Challenges

Toward A Syndemic View of Urban Health Challenges

Bobby MilsteinMinnesota Health Departments

December 18, 2003

Bobby MilsteinMinnesota Health Departments

December 18, 2003

The 2007 Urban CrossoverThe 2007 Urban Crossover

Emmi PC. Coupled human–biologic systems in urban areas: towards an analytical framework using dynamic simulation. 21st International Conference of the System Dynamics Society; New York; 2003.

United Nations. World urbanization prospects: the 2001 revision. New York: United Nations, 2002.

“Historically humans have

disproportionately favored a rural and

agriculturally based settlement pattern.

By the middle of the 20th century, thirty

percent of our species lived in urban areas.

Mankind is about to cross a cultural

threshold when in 2007 we become a

predominately urban species.”

“Historically humans have

disproportionately favored a rural and

agriculturally based settlement pattern.

By the middle of the 20th century, thirty

percent of our species lived in urban areas.

Mankind is about to cross a cultural

threshold when in 2007 we become a

predominately urban species.”

-- Philip Emmi-- Philip Emmi

Tamman M. Charlantingham: welcome to the big city. Atlanta Journal-Constitution 2001 April 15.

9.80

10.52

11.33 13.12

Source: NHTSA

2.51New York

3.76San Francisco

6.55Portland

9.80Houston

10.52Phoenix

11.33Dallas

13.12Atlanta

5.36Philadelphia

Automobile Fatality Rates by City, 1998(excluding pedestrian fatalities; deaths/100,000/year)

Automobile Fatality Rates by City, 1998(excluding pedestrian fatalities; deaths/100,000/year)

2.33New York

4.55San Francisco

2.58Portland

3.41Houston

4.09Phoenix

4.28Dallas

6.44Atlanta

1.88Philadelphia

Pedestrian Fatality Rates by City, 1998(deaths/100,000/year)

Pedestrian Fatality Rates by City, 1998(deaths/100,000/year)

Source: NHTSA

Health Effects of SprawlHealth Effects of Sprawl

Frumkin H. Urban sprawl and public health. Public Health Reports 2002;117(3):201-17.

Physical inactivity

Motor vehicle crashes

Pedestrian injuries/fatalities

Water quality and quantity

Air pollution

Heat extremes

Social capital erosion

Mental health problems

(Asthma, crime, racism, noise, soil erosion, fossil fuel depletion, others…)

Physical inactivity

Motor vehicle crashes

Pedestrian injuries/fatalities

Water quality and quantity

Air pollution

Heat extremes

Social capital erosion

Mental health problems

(Asthma, crime, racism, noise, soil erosion, fossil fuel depletion, others…)

Immense Challenges AheadImmense Challenges Ahead

King LJ. Safeguarding human and animal health: the changing face of veterinary medicine in 2002. National Press Club; Canberra, Australia: Veterinary Science Foundation, University of Sydney; 2002.

United Nations. Department of Economic and Social Development.. Population Division. World urbanization prospects: the 2001 revision. New York: United Nations, 2002.

“By 2015 there will be approximately

[21] mega cities that will each

approach populations of 10 million

inhabitants. This trend will

exacerbate and expand two new

health problems: built environmental

conditions and syndemics."

“By 2015 there will be approximately

[21] mega cities that will each

approach populations of 10 million

inhabitants. This trend will

exacerbate and expand two new

health problems: built environmental

conditions and syndemics."

-- Lonnie King-- Lonnie King

Growth of Major CitiesUrban Agglomerations of 5 million or more

0

10

20

30

40

50

60

70

1975 1980 1985 1990 1995 2000 2005 2010 2015

To

tal W

ord

wid

e

10+ million

5-10 million

Growth of Major CitiesUrban Agglomerations of 5 million or more

0

10

20

30

40

50

60

70

1975 1980 1985 1990 1995 2000 2005 2010 2015

To

tal W

ord

wid

e

10+ million

5-10 million

Ideas About InteractionIdeas About Interaction

Confounding

Connecting*

Synergism

Syndemic

* Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

Events

Systems

“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

Co-occurring

"The central urban areas and their suburbs only a few dozen miles away constitute, from a public

health viewpoint, a single, strongly interlinked urban-suburban ecosystem rather than the

almost random, fragmented, economically and racially segregated array their separate

governmental and budgetary systems imply."

"The central urban areas and their suburbs only a few dozen miles away constitute, from a public

health viewpoint, a single, strongly interlinked urban-suburban ecosystem rather than the

almost random, fragmented, economically and racially segregated array their separate

governmental and budgetary systems imply."

-- Rodrick & Deborah Wallace-- Rodrick & Deborah Wallace

Urban-Suburban EcosystemUrban-Suburban Ecosystem

Wallace R, Wallace D. Inner-city disease and the public health of the suburbs - socio-geographic dispersion of point source infection. Environment and Planning A 1993;25(12):1707-1723.

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.

Background on the Syndemics ProjectBackground on the Syndemics Project

Planned as a three-year study of innovations in health planning and evaluation (now in year two)

The word syndemic signals special concern for relationships

mutually reinforcing character of health problems

connections between health status and living conditions

synergy/fragmentation within the health system (by issues; sectors; organizations; professionals and citizens)

Planned as a three-year study of innovations in health planning and evaluation (now in year two)

The word syndemic signals special concern for relationships

mutually reinforcing character of health problems

connections between health status and living conditions

synergy/fragmentation within the health system (by issues; sectors; organizations; professionals and citizens)

Placing Health in a Wider Set of Relationships

Placing Health in a Wider Set of Relationships

Health

LivingConditions

Capacity toAct

Innovations in Public Health WorkInnovations in Public Health WorkSteps in Public Health Problem Solving Trends and Emerging Priorities

Define the problem

Eliminate health disparities

Avoid activity limitation

Promote life satisfaction

Increase healthy days

Determine the cause

Social determinants of health

Income inequality

Eroding social capital

Unhealthy built environment

Adverse childhood experiences

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

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, practical)Concerned with creating and protecting values like health, 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, practical)Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends

Innovations Point to the Emergence of a Syndemic Orientation

Innovations Point to the Emergence of a Syndemic Orientation

Many other orientations rely on disconnected, singular, and unthinking approaches to means and ends (e.g., security by means of war)

Many other orientations rely on disconnected, singular, and unthinking approaches to means and ends (e.g., security by means of war)

A Complementary Science of Relationships

A Complementary Science of Relationships

Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a Health System that Protects the Public’s HealthDynamic interaction among multiple problems, problem solvers, and responses

Efforts to Reduce Population Health ProblemsProblem, problem solver, response

Efforts to Organize a Health System that Protects the Public’s HealthDynamic interaction among multiple problems, problem solvers, and responses

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. Infant

mortality and endemic disease became matters of social

responsibility. 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. Infant

mortality and endemic disease became matters of social

responsibility. 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

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

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor community health?

Changing (and Accumulating) Ideas in Causal Theory

What accounts for poor community 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 response capacity (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 response capacity (syndemic)

1880

1950

1960

1980

2000

1840

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

600

500

400

200

100

50

1950 1960 1970 1980 1990 1995

Rate if trend continued

Peak Rate

Actual Rate

Ag

e-a

dju

sted

Death

Rate

per

10

0,0

00

Pop

ula

tion

1955 1965 1975 1985

300

700

Year

Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998

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."

"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."

Benefits of SpecializationBenefits of Specialization

-- John Scott-- John Scott

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!

But “Solutions” Can Also Create New Problems

But “Solutions” Can Also Create 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.

Side Effects of SpecializationSide Effects of Specialization

Confusion

Inefficiency

Competition

Coercive power dynamics

Neglected feedback (+ and -)

Confounded evaluations

Limited mandate to address living conditions and capacity

Disappointing track record, especially with regard to inequalities

Confusion

Inefficiency

Competition

Coercive power dynamics

Neglected feedback (+ and -)

Confounded evaluations

Limited mandate to address living conditions and capacity

Disappointing track record, especially with regard to inequalities

A

C

BD

E

A B C D EInstitutions

Community

Dangers of Remaining Too SpecificDangers of Remaining 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

Conventional problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

Obscures patterns that transcend any specific problem

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.

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.

Source: Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2003. Accessed March 21 at <http://apps.nccd.cdc.gov/HRQOL/>.

The picture looks different if we think about people’s overall state of health or affliction

The picture looks different if we think about people’s overall state of health or affliction

14% increase

Public Health Goals Are Expanding…and Accumulating

Public Health Goals Are Expanding…and Accumulating

Prevent disease and injury (~1850 -- present)

Promote health and human development (1974 -- present)

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

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

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

-- Albert Einstein

Is there some way to get a larger, more dynamic overview of the whole health

system without loosing sight of unique disease processes involved?

Is there some way to get a larger, more dynamic overview of the whole health

system without loosing sight of unique disease processes involved?

Public Work (organizing, governance, citizenship, mutual accountability)

Professional Work (customers, products, services)

more inter-organizationally complex, slower rate of improvement

organizationally complex, faster rate of improvement

FOR SELF INTEREST FOR OTHERS IN NEED

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Afflicted

Afflictedwithout

Complications DevelopingComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Afflicted withComplications

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

From: 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.

Basic Dynamics in the Health System Basic Dynamics in the Health System

“Living conditions are the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic

circumstances and the physical environment – all of which can impact

upon health – and are largely outside of the immediate control of the individual.”

“Living conditions are the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic

circumstances and the physical environment – all of which can impact

upon health – and are largely outside of the immediate control of the individual.”

-- World Health Organization-- World Health Organization

Definition:Living Conditions

Definition:Living Conditions

World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.

Dependence on Living ConditionsDependence on Living Conditions

Corning PA. Presidential speech: the systems sciences in the year 3000. International Society of the Systems Sciences, 2000. Accessed April 23, 2002 at <http://www.complexsystems.org/commentaries/jul00.html>.

"Each of us has an array of basic needs that must, by and large,

be satisfied continuously. We cannot, for instance, do for very

long without fresh water, or waste elimination, or sleep.

Accordingly, each of us–individually and collectively–requires a

synergistic ‘package' of resources and suitable environmental

conditions. A society that can reliably provide this package will

thrive and possibly grow larger. But if even one of these needs

is not satisfied–if any part of the package is deficient–the entire

enterprise is likely to be threatened"

"Each of us has an array of basic needs that must, by and large,

be satisfied continuously. We cannot, for instance, do for very

long without fresh water, or waste elimination, or sleep.

Accordingly, each of us–individually and collectively–requires a

synergistic ‘package' of resources and suitable environmental

conditions. A society that can reliably provide this package will

thrive and possibly grow larger. But if even one of these needs

is not satisfied–if any part of the package is deficient–the entire

enterprise is likely to be threatened"

Seeing Conditions as FreedomsSeeing Conditions as Freedoms

Adverse living conditions are circumstances that inhibit people's freedom to live and develop their full potential.

They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection).

Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions.

Adverse living conditions are circumstances that inhibit people's freedom to live and develop their full potential.

They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection).

Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions.

Prerequisite Conditions for HealthPrerequisite Conditions for Health

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

Endorsed at all five world conferences on health promotion (1986-2000)

Endorsed at all five world conferences on health promotion (1986-2000)

Peace

Shelter

Education

Food

Peace

Shelter

Education

Food

Income

Stable eco-system

Sustainable resources

Social justice and equity

Income

Stable eco-system

Sustainable resources

Social justice and equity

Human Development FreedomsHuman Development Freedoms

Health

Education

Standard of living

Political participation

Social engagement

Physical security

Health

Education

Standard of living

Political participation

Social engagement

Physical security

Sen AK. Development as freedom. New York: Anchor books, 1999.

United Nations Development Programme. Human development report 2002: deepening democracy in a fragmented world. New York: Oxford University Press; 2002.

UNDP Human Development Index

UNDP Human Development Index

Choice and Non-ChoiceChoice and Non-Choice

Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93.

“If we aim to affect health behavior, we have to examine the

circumstance that generate behavior and understand the relation of

choice to non-choice. Choices are always made from among

alternatives presented by the social environment, or by circumstances

that were themselves not chosen. Choice depends on the tools for

making choices, the outer edge of people's aspirations as they have

been encouraged or dampened by past experience. When we

recognize the elements of non-choice in choice, we can escape the

contradiction between social causation and individual responsibility

and understand the interactiveness of the two.”

“If we aim to affect health behavior, we have to examine the

circumstance that generate behavior and understand the relation of

choice to non-choice. Choices are always made from among

alternatives presented by the social environment, or by circumstances

that were themselves not chosen. Choice depends on the tools for

making choices, the outer edge of people's aspirations as they have

been encouraged or dampened by past experience. When we

recognize the elements of non-choice in choice, we can escape the

contradiction between social causation and individual responsibility

and understand the interactiveness of the two.”

Linking Living Conditions to FreedomsLinking Living Conditions to FreedomsHealthy State Freedom From… Selected Examples

Physical security Physical extremes Crash, fire, fall

Heat, cold

Radiation

Hazardous substances

Natural disaster

Infectious diseases

Peace Violence Homicide

Suicide

War

Rape

Minimal standard of living

Deprivation Malnutrition

Homelessness

Poverty

Joblessness

Overcrowding

Illiteracy

Inadequate education

Social engagement Disconnection Inequality

Injustice

Dependency

Incarceration

Runaway

Neglect

Stable organic processes

Impaired metabolism

Heart disease

Cancer

Stroke

Diabetes

Arthritis

Obesity

Mental/emotional balance

Impaired cognition or emotion

Depression

Anxiety

Attention deficit

Lack of recreation

Successful reproduction

Impaired reproduction

Infertility

Miscarriage

Birth defects

Infant mortality

Areas of EmphasisAreas of Emphasis

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Afflicted

Afflictedwithout

Complications DevelopingComplications

Afflicted withComplications

Targetedprotection

Primaryprevention

Secondaryprevention

Dying fromComplications

Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

World of Providing…

• Education• Screening• Disease management • Pharmaceuticals• Clinical services• Physical and financial access• Etc…

Medical and Public Health Policy

DISEASE AND RISK MANAGEMENT

World of Transforming…

• Deprivation• Dependency• Violence• Disconnection• Environmental decay• Stress• Insecurity• Etc…

By Strengthening…

• Leaders and institutions• Foresight and precaution• The meaning of work• Mutual accountability• Plurality• Democracy• Freedom• Etc…

Healthy Public Policy & Public Work

DEMOCRATIC SELF-GOVERNANCE

Two Policy OrientationsTwo Policy Orientations

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.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.

Healthy Public Policy Medical and Public Health Policy

Concerned chiefly with assuring safer, healthier conditions for all

Concerned chiefly with preventing and alleviating specific diseases, managing complications, and delaying premature death or disability

Relies heavily on multiple, small-scale, local solutions, with low technology

Relies heavily on specific high-technology solutions, widely applied

Combines analyses into a broad systems view, transcending sector boundaries

Confines analyses to the health sector

Future-oriented (reacting to long-term dynamics)

Present-oriented (reacting to immediate events)

Questions the givens, focuses on plausible outcomes

Accepts the givens, focuses on probable outcomes

Evaluated first through simulation, then through implementation

Evaluated through implementation

Main resources are citizen leadership and broad-based public work (including that of professionals)

Main resources are money, professional expertise, and technology (often excluding citizen leadership)

Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation

System Dynamics

SocialNavigation

POLICYDEVELOPMENT

ASSESSMENT

ASSURANCE

NetworkAnalysis

CategoricalOrientationSyndemic

Orientation

Internal FocusInternal Focus

“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.

For Additional Informationhttp://www.cdc.gov/syndemics