Toward a Syndemic View of Environmental Health Challenges Bobby Milstein NCEH Dialogue July 28, 2003...

Toward a Syndemic View of Environmental Health Challenges

Toward a Syndemic View of Environmental Health Challenges

Bobby MilsteinNCEH Dialogue

July 28, 2003

Bobby MilsteinNCEH Dialogue

July 28, 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

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

QuestionsQuestions

What is a syndemic?

Why might syndemics develop under changing environmental conditions (e.g., urbanization, sprawl)?

What concepts and methods are available for planning and evaluating initiatives to prevent syndemics?

How do those approaches relate to conventional epidemiological techniques?

What must be done to prepare the public and the public health workforce to adopt a syndemic orientation?

What is a syndemic?

Why might syndemics develop under changing environmental conditions (e.g., urbanization, sprawl)?

What concepts and methods are available for planning and evaluating initiatives to prevent syndemics?

How do those approaches relate to conventional epidemiological techniques?

What must be done to prepare the public and the public health workforce to adopt a syndemic orientation?

A Glimpse Into 2020A Glimpse Into 2020

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

A Glimpse Into 2020A Glimpse Into 2020

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

On the List

War

HIV

Violence

Self-inflicted injury

Cancer of the trachea, bronchus, and lung

On the List

War

HIV

Violence

Self-inflicted injury

Cancer of the trachea, bronchus, and lung

Off the List

Measles

Malaria

Falls

Anemia

Malnutrition

Off the List

Measles

Malaria

Falls

Anemia

Malnutrition

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.

"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. Berry W. Solving for pattern. In: The Gift of Good Land. San Francisco: North Point; 1981. p. 134-45.

Solving for PatternSolving for Pattern

Solutions Can Also Create ProblemsSolutions Can Also Create 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.

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

Crafting Healthy PlacesCrafting Healthy Places

Cultivating a Place-Based ViewCultivating a Place-Based View

"How do you know," I asked, "that in

twenty years those things that you

consider special are still going to be

here?" At first they all raised their

hands but when they really digested

the question every single one of them

put their hands down. In the end,

there was not a single hand up. No

one could answer that question…”

"How do you know," I asked, "that in

twenty years those things that you

consider special are still going to be

here?" At first they all raised their

hands but when they really digested

the question every single one of them

put their hands down. In the end,

there was not a single hand up. No

one could answer that question…”

-- Nainoa Thompson-- Nainoa Thompson

Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.

Enacting a Place-Based ViewEnacting a Place-Based View

Malama Hawaii. Vision, mission, and guiding values. Malama Hawaii, 2003. Accessed July 28, 2003 at <http://www.malamahawaii.org/present.php>.Malama Hawaii. Vision, mission, and guiding values. Malama Hawaii, 2003. Accessed July 28, 2003 at <http://www.malamahawaii.org/present.php>.

“Public health is what we, as a society, do collectively to assure the conditions in which

people can be healthy.”

“Public health is what we, as a society, do collectively to assure the conditions in which

people can be healthy.”

-- Institute of Medicine-- Institute of Medicine

Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988.

Institute of Medicine. The future of the public's health in the 21th century. Washington D.C.: National Academy Press, 2002.

Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988.

Institute of Medicine. The future of the public's health in the 21th century. Washington D.C.: National Academy Press, 2002.

Public Health Goals Are ExpandingPublic Health Goals Are Expanding

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

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

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

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?

Virtually Unstoppable Trends in Prevention Science

Virtually Unstoppable Trends in Prevention Science

Systems-oriented

Politically engaged

Philosophically conscious

Systems-oriented

Politically engaged

Philosophically conscious

What Is Not HappeningWhat Is Not Happening

Integration

Dynamic hypotheses of multiple health states and rates

Policy testing through simulation

Searching for polices that can be effective

Rehearsing policy implementation

Learning about dynamic complexity

Greater effectiveness in aligning and implementing policies

Integration

Dynamic hypotheses of multiple health states and rates

Policy testing through simulation

Searching for polices that can be effective

Rehearsing policy implementation

Learning about dynamic complexity

Greater effectiveness in aligning and implementing policies

Need A Complementary Science of RelationshipsNeed A Complementary Science of Relationships

Problem, problem solver, response

Coordination of multiple problems, problem solvers, and responses

Problem, problem solver, response

Coordination of multiple problems, problem solvers, and responses

Expanding Prevention ScienceExpanding Prevention Science“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 ResnickSyndemic Orientation

People

Problems

Time

Values

EpidemicOrientation

Promise of a Syndemic ViewPromise of a Syndemic View

See the public health enterprise in larger, more dynamic terms

Shift from a stepwise view of change to one that is transformative

Expand prevention science by formalizing new kinds of principles and processes (e.g., causal feedback)

Develop a vocabulary for thinking about the dynamics of health, ecology, society, and democratic citizenship

See the public health enterprise in larger, more dynamic terms

Shift from a stepwise view of change to one that is transformative

Expand prevention science by formalizing new kinds of principles and processes (e.g., causal feedback)

Develop a vocabulary for thinking about the dynamics of health, ecology, society, and democratic citizenship

Plan for TodayPlan for Today

Brief history of syndemic thinking and its connection to changing urban-suburban ecosystems

Progress in defining a syndemic orientation

Efforts to model syndemic growth and control

Future directions

Brief history of syndemic thinking and its connection to changing urban-suburban ecosystems

Progress in defining a syndemic orientation

Efforts to model syndemic growth and control

Future directions

Two or more afflictions, interacting

synergistically, contributing to excess

burden of disease in a population.

Two or more afflictions, interacting

synergistically, contributing to excess

burden of disease in a population.

Working Definition:Syndemic

Working Definition:Syndemic

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.

“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

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


-- Sufi Saying

Co-occurring

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.

Event Oriented View

Problem Results

Goals

Situation

Decision

SideEffects

Systems View

Goals

Environment

Decisions

Goals ofOthers

Actions ofOthers

Syndemic orEpidemics With the Same Root Cause?

Syndemic orEpidemics With the Same Root Cause?

Incidence rate

Recovery rate

Severity burden

Incidence rate

Recovery rate

Severity burden

Common causes

Same biological agent

Same risk behaviors

Similar environments

Managed by same or similar organizations

Common causes

Same biological agent

Same risk behaviors

Similar environments

Managed by same or similar organizations

DirectDirect IndirectIndirect

A Synergism of PlaguesA Synergism of Plagues

Wallace D, Wallace R. A plague on your houses: how New York was burned down and national public health crumbled. New York: Verso, 1998.

“Out of the overcrowding and the social

unraveling of the community came epidemics

of contagious disease and contagious

behavior problems both in the remnants of the

burned out neighborhoods and in the newly

crowded neighborhoods receiving refugees:

tuberculosis, measles, substance abuse,

AIDS, low‑weight births, and violence."

“Out of the overcrowding and the social

unraveling of the community came epidemics

of contagious disease and contagious

behavior problems both in the remnants of the

burned out neighborhoods and in the newly

crowded neighborhoods receiving refugees:

tuberculosis, measles, substance abuse,

AIDS, low‑weight births, and violence."

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

"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.

"The probability of a large disease outbreak in a susceptible suburban community will increase

inexorably with the time the central city outbreak remains uncontrolled, at a rate

proportional to the disease burden of that urban epicenter as modulated by the commuting

field."

"The probability of a large disease outbreak in a susceptible suburban community will increase

inexorably with the time the central city outbreak remains uncontrolled, at a rate

proportional to the disease burden of that urban epicenter as modulated by the commuting

field."-- Rodrick & Deborah Wallace-- Rodrick & Deborah Wallace

Concentration Is Not ContainmentConcentration Is Not Containment

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.

Ecosocial Distress SyndromeEcosocial Distress Syndrome

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

“In the long run our ‘patient’ is the species,

suffering from an ecosocial distress

syndrome that links the daunting problems

of resource depletion, resurgent disease,

pollution, inequality, oppression, climate

change, and alienation.”

“In the long run our ‘patient’ is the species,

suffering from an ecosocial distress

syndrome that links the daunting problems

of resource depletion, resurgent disease,

pollution, inequality, oppression, climate

change, and alienation.”

-- Richard Levins & Cynthia Lopez-- Richard Levins & Cynthia Lopez

Spectrum of PreventionSpectrum of Prevention

SHORTmonths-years

INTERMEDIATEyears-decades

LONGdecades-centuries

Time Horizon for Observing Effects on Population Health Status*

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

SECONDARY &TERTIARY

Biological Change

Healing Services

Focus on Affliction

PRIMARY & SECONDARY

BehavioralChange

Focus on RiskDisease Prevention

INTERGENERATIONAL

Social Change

Focus on ConditionsHealth Promotion

Focus on Capacity for ActionCapacity Building or Empowerment

Infrastructural Change

Two Policy OrientationsTwo Policy OrientationsPublic Health Policy Healthy Public Policy

Concerned chiefly with preventing and alleviating affliction

Concerned chiefly with assuring healthful conditions

Relies heavily on singular high technology solutions, widely applied

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

Confines analyses to the health sector

Expands to an holistic synthesis, transcending sector boundaries

Present oriented Future oriented

Accepts the givens Questions 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.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.

Conventional Problem Solving Approach

Conventional 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 Specialization

Noise

Inefficiency

Competition

Coercive power dynamics

Neglected feedback (+ and -)

Confounded evaluations

Limited mandate to address living conditions and capacity

Disappointing track record

Noise

Inefficiency

Competition

Coercive power dynamics

Neglected feedback (+ and -)

Confounded evaluations

Limited mandate to address living conditions and capacity

Disappointing track record

A

C

BD

E

A B C D EInstitutions

Community

Specialization Invites FragmentationSpecialization Invites Fragmentation

Conventional , event-oriented problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

Conventional , event-oriented problem solving proliferates problems

Opens a self-reinforcing niche for professional problem solvers

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.

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

Disparity

Disarray

Disorientation

Identify community

Cooperate with community members in:

Identifying afflictions and their relationships

Examining living conditions and why they differ

Devising beneficial system-wide policies

Strengthening capacity to act

Directing the course of social change to assure the conditions for health for all

Expand to other communities, as necessary

Identify community

Cooperate with community members in:

Identifying afflictions and their relationships

Examining living conditions and why they differ

Devising beneficial system-wide policies

Strengthening capacity to act

Directing the course of social change to assure the conditions for health for all

Expand to other communities, as necessary

Steps in a Syndemic ApproachSteps in a Syndemic Approach

Minimum Boundary for Syndemic Thinking

Minimum Boundary for Syndemic Thinking

Health

LivingConditions

Capacity toAct

The Overview EffectThe Overview Effect

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

Seeing Beyond the ProbableSeeing Beyond the Probable

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

Relational Questions and Data Requirements

Relational Questions and Data Requirements

AssessmentNetwork Analysis

Policy DevelopmentSystem Dynamics

AssuranceSocial Navigation

What links to what?

What influences what?

What policies have the greatest leverage?

What backlash could occur?

Where are we going?

Where are we now?

How close are we?

Where can we go from here?

Proximity Data Feedback Data Navigational Data

Syndemic Orientation

Syndemic View Systems View

Navigational View

Formalizing an OrientationFormalizing an Orientation

X Y

AssessmentAssessment

Capacity to Act

Living Conditions

Ties

Afflictions


-- Sufi Saying


-- Sufi Saying

On the Right Track With MAPPOn the Right Track With MAPP

Community

Systems

Strategic

Community

Systems

Strategic

Available from NACCHO at http://nacchoweb.naccho.org/MAPP_Home.asp

Health Topics A-ZHealth Topics A-Z

Preliminary Affliction Typology>100 Classified Into Seven Types

Preliminary Affliction Typology>100 Classified Into Seven Types

Healthy States Unhealthy Deviations

Physical security Physical extremes

Peace Violence

Minimal standard of living Deprivation

Social engagement Disconnection

Stable organic processes Impaired metabolism

Mental/emotional balance Impaired cognition/emotion

Successful reproduction Impaired reproduction

Preliminary Affliction TypologyPreliminary Affliction TypologyHealthy State Deviation Selected Afflictions

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

Unemployment

Overcrowding

Illiteracy

Social engagement Disconnection Inequality

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

Cross-Impact MatrixCross-Impact Matrix

Policy DevelopmentPolicy Development

Explicit model building

Simulated experiments

What if…

What futures are possible?

Real world action and observation

Explicit model building

Simulated experiments

What if…

What futures are possible?

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

Brief History of Causal TheoryWhat accounts for poor community health?

Brief History of Causal TheoryWhat 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 community 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 community capacity (syndemic)

1880

1950

1960

1980

2000

1840

“[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

From: http://www.systemdynamics.org/

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

From: http://www.systemdynamics.org/

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

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 DevelopmentTools for Policy Development

Developed by Jack Homer, Homer ConsultingDeveloped by Jack Homer, Homer Consulting

Patterns

Structure

Events

Progression of Systems Thinking & Modeling

Progression of Systems Thinking & Modeling

Adapted from: Successful Systems, Inc.Adapted from: Successful Systems, Inc.

IssueIdentification

Variable & Behavior Analysis

Causal Loop Mapping

SimulationModeling

Understanding Strategy &Policy Implications

Implementing Action Plan

Time

IssueIdentification

Variable & Behavior Analysis

Causal Loop Mapping

KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop

Preliminary Dynamic Hypothesis Under What Conditions Do Syndemics Emerge?

How Can they be Controlled?



Adapted from: Homer J, Milstein B. Communities with multiple afflictions: a system dynamics approach to the study and prevention of syndemics. 20th International Conference of the System Dynamics Society; Palermo, Italy; 2002.


Afflictionprevalence &

burden

Adverseliving

conditions

Effort to alleviate andprevent affliction

Effort to improveliving conditions

R1

R3a

R4a

R4b

B1b

B1a

Communitystrength

Outside assistance toalleviate and prevent

affliction

Outside assistanceto improve living

conditions

R2b

At-risk fraction

Afflictioncross-impacts

Social disparity

R2a Public work fraction

Outside assistance tobuild community

strength

United efforts

R2c

Magnitude ofefforts

Divided efforts

R3b

Afflictionprevalence& burden

Adverseliving

conditions

Communitystrength








Afflictionprevalence &

burden

Adverseliving

conditions



R1

R3a

R4a

R4b

B1b

B1a

Communitystrength


affliction


conditions

R2b

At-risk fraction


Social disparity

R2a Public work fraction

Outside assistance tobuild community

strength

United efforts

R2c

Magnitude ofefforts

Divided efforts

R3b

Afflictionprevalence& burden

Adverseliving

conditions

Communitystrength

R1

At-risk fraction



B1a


B1b

Effort to buildcommunity strength

B1c

Social disparityR2c

R2b

R2a

R3a

Public work fraction

United efforts

Divided efforts

R3b Magnitude ofameliorative efforts

R3c

R3d


affliction


conditions

Outside assistanceto build community

strength


About the Feedback LoopsAbout the Feedback LoopsSyndemic: Each affliction increases vulnerability to other afflictions, thereby amplifying the effect of increases or decreases in the prevalence of individual afflictions.

Community Response: The community makes efforts to fight affliction and adverse living conditions in response to their prevalence, and to build greater community strength when it is perceived as low. Outside assistance may bolster such efforts.

Social Disparity and Community Strength: These efforts, especially those to fight adverse living conditions, are greater in magnitude when the community is strong and unified. But community strength is hindered by social disparity, which, in turn, is made worse by the very afflictions and adverse living conditions the efforts are trying to fight.

Community Strength and Public Work: Community strength is also affected by the efforts themselves. When problems spread in a strong community, a united response (public work) reinforces the community’s strength. Conversely, when problems spread in a weak community, a divided response (professional work) reinforces the community’s weakness. Outside assistance given to a weak community for problem fighting may amplify the divided response and undermine the community’s internal response capability. Outside assistance to build community strength may prepare the community to make a more united response.

Syndemic: Each affliction increases vulnerability to other afflictions, thereby amplifying the effect of increases or decreases in the prevalence of individual afflictions.

Community Response: The community makes efforts to fight affliction and adverse living conditions in response to their prevalence, and to build greater community strength when it is perceived as low. Outside assistance may bolster such efforts.

Social Disparity and Community Strength: These efforts, especially those to fight adverse living conditions, are greater in magnitude when the community is strong and unified. But community strength is hindered by social disparity, which, in turn, is made worse by the very afflictions and adverse living conditions the efforts are trying to fight.

Community Strength and Public Work: Community strength is also affected by the efforts themselves. When problems spread in a strong community, a united response (public work) reinforces the community’s strength. Conversely, when problems spread in a weak community, a divided response (professional work) reinforces the community’s weakness. Outside assistance given to a weak community for problem fighting may amplify the divided response and undermine the community’s internal response capability. Outside assistance to build community strength may prepare the community to make a more united response.

R1

B1

R3

R2

The community is relatively poor and unfocused, and has significant afflictions, adverse living conditions, and low community strength:

• Affliction Prevalence initial: 17%

• Adverse living conditions Initial: 22% ‘Baseline’: 26% (Where system would settle absent any living conditions programs;reflects community income level)

• Community strength Initial: 29%

‘Baseline’: 40%(Where system would settle absent any social disparity, and with a neutral balance of public and professional work; reflects extent of common purpose and commitment)

Community SpecificsCommunity Specifics

• Affliction

Baseline at risk fraction 10%

Max additional at risk fraction from affliction cross impact 40%

Max additional at risk fraction from living conditions 75%

Baseline non-contagious incidence rate (% of at-risk) 10%/year

Baseline contagious incidence rate (% of at-risk contacted) 60%/year

Baseline affliction recovery rate 10%/year

Effect of max programs on affliction incidence 60%

Effect of max programs on affliction severity 60%

Effect of max programs on affliction recovery 200%

Affliction prevalence causing full program demand 20%

Internal capacity for affliction pgms if no commun strength 33%

Max boost in affliction programs from assistance 30%

Other Assumptions (1)Other Assumptions (1)

• Adverse living conditions

Living conditions improvement time 4 years

Living conditions erosion time 8 years

Effect of max programs on adverse living conditions 50%

Adverse living conditions causing full program demand 20%

Internal capacity for LC programs if no community strength 0%

Max boost in LC programs from assistance 50%

• Social Disparity

Affliction prevalence indicating 100% social disparity 50%

Adverse conditions prevalence indicating 100% disparity 50%

Weight on affliction (vs. living conditions) for social disparity 40%


• Community Strength

Community strength development time 4 years

Community strength erosion time 8 years

Effect of max social disparity on community strength 50%

Effect of max public work on community strength 200%

Effect of max professional work on community strength 50%

Max public work fraction (when strength=100%) 80%

Weight on affliction (vs. conditions) programs for strength 50%

Max boost in community strength from assistance 30%


Four Scenarios for Affliction Burden

Development of a SyndemicDevelopment of a Syndemic

12

10

8

6

4

0 2 4 6 8 10 12 14 16 18 20Time (years)

Affliction burden : GBasicAffliction burden : GMARCIbAffliction burden : GBALCbAffliction burden : GBCSb

Basic scenario: Poor living conditions, weak community, intertwined afflictions

Weaker cross-impacts among afflictions

Better living conditions

Greater community strength

Avg unhealthy days per person per month

Evaluating Policy ScenariosEvaluating Policy Scenarios

Focus assistance on…

Fighting affliction

Improving adverse living conditions

Building community strength

Focus assistance on…

Fighting affliction

Improving adverse living conditions

Building community strength

Different proportions

Different combinations

Different sequences

Different proportions

Different combinations

Different sequences

Alternative Investment StrategiesAlternative Investment Strategies

Public Health Programming Social Programming Community Organizing

FLAT: No outside assistance

AF100: 100% of assistance goes to fight afflictions

LC100: 100% of assistance goes to improve living conditions

CS100: 100% of assistance goes to build community strength

AF50LC50: 50% to fight afflictions, 50% to improve conditions

AF50CS50: 50% to fight afflictions, 50% to build strength

LC50CS50: 50% to improve conditions, 50% to build strength

AF30LC30CS40: 30% afflictions, 30% conditions, 40% strength

Tests of Outside AssistanceAssistance starts at Year 0 and ends at Year 12; in the following tests the split of assistance is held fixed for the entire 12 years

Tests of Outside AssistanceAssistance starts at Year 0 and ends at Year 12; in the following tests the split of assistance is held fixed for the entire 12 years

AF100 is best at reducing affliction when assistance is active, but falls to worst after assistance is cut off.CS100 is best after the assistance is cut off, but does less to reduce affliction during the time of assistance.

A mix like AF50CS50 that includes both affliction fighting and strength building does reasonably well during both time periods.

Affliction burden

60

40

20

0 2 4 6 8 10 12 14 16 18 20Time (years)

Affliction burden : flatAffliction burden : af100Affliction burden : lc100Affliction burden : cs100Affliction burden : af50lc50Affliction burden : af50cs50Affliction burden : lc50cs50Affliction burden : af30lc30cs40

Average number of unhealthy days per person per year

Tests of Outside AssistanceAssistance starts at Year 0 and ends at Year 12; in the following

tests the split of assistance may shift in each 4-year interval

Tests of Outside AssistanceAssistance starts at Year 0 and ends at Year 12; in the following

tests the split of assistance may shift in each 4-year interval

Assistance Scenario

Yeas 0-4 Years 5-8 Years 9-12

CS1AF 11 CS 100% AF 100% AF 100%

AF111 AF 100% AF 100% AF 100%

LC111 LC 100% LC 100% LC 100%

CS111 CS 100% CS 100% CS 100%

Homer J, Milstein B. Optimal decision making in a dynamic model of poor community health. Hawaii International Conference on System Science; Big Island, Hawaii; 2004.Homer J, Milstein B. Optimal decision making in a dynamic model of poor community health. Hawaii International Conference on System Science; Big Island, Hawaii; 2004.

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

Comparing Affliction Burden under Basic Setting and Four Different Assistance Schemes

Comparing Affliction Burden under Basic Setting and Four Different Assistance Schemes

Affliction assistance only “AF111”Conditions assistance only “LC111”

Strength assistance only “CS111”

Optimal assistance scheme “CS1AF11”

Avg affliction burden T4-T20:8.18.58.88.3

Policy HypothesesInvest Early in Building Strength

Policy HypothesesInvest Early in Building Strength

The first priority of philanthropies and government in addressing communities that are weak and struggling against multiple afflictions should be to assist in building community strength (enabling a greater degree of citizen-led public work), perhaps even before substantial assistance is provided for direct fighting of prevalent diseases.

The first priority of philanthropies and government in addressing communities that are weak and struggling against multiple afflictions should be to assist in building community strength (enabling a greater degree of citizen-led public work), perhaps even before substantial assistance is provided for direct fighting of prevalent diseases.

Policy HypothesesBeware the Side Effects of Outside

Assistance Related to Living Conditions

Policy HypothesesBeware the Side Effects of Outside

Assistance Related to Living Conditions

Outside assistance aimed directly at improving living conditions may often be insufficiently cost-effective, due to time lags and unintended side effects, to warrant making such assistance a high priority in the absence of widespread citizen participation

Outside assistance aimed directly at improving living conditions may often be insufficiently cost-effective, due to time lags and unintended side effects, to warrant making such assistance a high priority in the absence of widespread citizen participation

Structural Reasons for Policy Resistance

Structural Reasons for Policy Resistance

Problem-fighting programs may have perverse effects on community strength when the community is weak and divided to begin with

Problem-fighting programs may have perverse effects on community strength when the community is weak and divided to begin with

Barriers to Learning in OrganizationsBarriers to Learning in Organizations

Dynamic complexity

Time delays

Inadequate and ambiguous feedback

Poor reasoning skills

Defensive reactions

Inability and costs of experimentation

Dynamic complexity

Time delays

Inadequate and ambiguous feedback

Poor reasoning skills

Defensive reactions

Inability and costs of experimentation

Sterman J. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000.

Benefits of Game-Based LearningBenefits of Game-Based Learning

Compressed time

Actions can be stopped or reversed

Experimental control of all conditions

Complete, undistorted, immediate results

Rehearse worse-before-better scenarios

Early warning of unintended effects

Opportunity to assemble stronger support

Compressed time

Actions can be stopped or reversed

Experimental control of all conditions

Complete, undistorted, immediate results

Rehearse worse-before-better scenarios

Early warning of unintended effects

Opportunity to assemble stronger support

“Artful scenario spinning…ensures not that you are always right about the future but--better--that you are almost never wrong."

-- Stewart Brand

“Artful scenario spinning…ensures not that you are always right about the future but--better--that you are almost never wrong."

-- Stewart Brand

Syndemics Simulation Game http://broadcast.forio.com/sims/syndemic2003/

http://broadcast.forio.com/sims/syndemic2003/






AssuranceAssurance

Implement policies by aligning health with other avenues of social change

Driven by citizen leaders in partnership with health professionals

Navigational perspective, guided by community vision and values

Forward orientation

Adapts to changing conditions

Implement policies by aligning health with other avenues of social change

Driven by citizen leaders in partnership with health professionals

Navigational perspective, guided by community vision and values

Forward orientation

Adapts to changing conditions

“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

Too Busy To HateToo Busy To Hate

"America was not on a road to survival

before Martin Luther King. Atlanta

would not look like the thriving

metropolis that it is now. Atlanta would

probably look more like Beirut if history

had gone its normal course, the normal

violent American way."

"America was not on a road to survival

before Martin Luther King. Atlanta

would not look like the thriving

metropolis that it is now. Atlanta would

probably look more like Beirut if history

had gone its normal course, the normal

violent American way."

-- Andrew Young-- Andrew Young

From: Kearns K. In Remembrance of Martin. PBS Video, 1999.

Formal Navigational ImageryFormal Navigational Imagery

See NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.aspSee NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.asp

Basic Concepts in Navigational ScienceBasic Concepts in

Navigational Science

Position (current state)

Destination (goals, values, ethics)

Direction (chosen course, policies)

Distance (difference from goal)

Drift (deflection from course)

Set (distance to get back on course)

Conditions (physical, historical or evolutionary context)

Position (current state)

Destination (goals, values, ethics)

Direction (chosen course, policies)

Distance (difference from goal)

Drift (deflection from course)

Set (distance to get back on course)

Conditions (physical, historical or evolutionary context)

Time

Energy

Resistance

Alignment

Guidance

Navigational aids

Charting

Time

Energy

Resistance

Alignment

Guidance

Navigational aids

Charting

“The people's health...is a concern of the people themselves.

They must want health. They must struggle for it and plan for

it. Physicians are merely experts whose advice is sought in

drawing up plans and whose cooperation is needed in

carrying them out. No plan, however well devised and well

intentioned, will succeed if it is imposed on the people. The

war against disease and for health cannot be fought by

physicians alone. It is a people's war in which the entire

population must be mobilized permanently.”

“The people's health...is a concern of the people themselves.

They must want health. They must struggle for it and plan for

it. Physicians are merely experts whose advice is sought in

drawing up plans and whose cooperation is needed in

carrying them out. No plan, however well devised and well

intentioned, will succeed if it is imposed on the people. The

war against disease and for health cannot be fought by

physicians alone. It is a people's war in which the entire

population must be mobilized permanently.”

-- Henry Sigerist-- Henry Sigerist

Sigerist HE. Health. Journal of public health policy. 1996;17(2):204-234.Sigerist HE. Health. Journal of public health policy. 1996;17(2):204-234.

Public Health as Public WorkPublic Health as Public Work

A Different Kind of PoliticsA Different Kind of Politics

Productive

People’s institutions

Cultural organizing

Productive

People’s institutions

Cultural organizing

From: Boyte HC. 21st century populism. The Nation 2002;in press.

Selected Navigational StatisticsSelected Navigational Statistics

a°

rh

a = 52°

r = 0.76n = 5

p=.05*

Adapted from: Baker RR. Human navigation and the sixth sense. New York, NY: Simon and Schuster. 1981.

Oriana website: http://www.kovcomp.co.uk/oriana/



Selected Navigational StatisticsSelected Navigational Statistics





a°

rh

a = 52°

r = 0.76n = 5

p=.05*

a°

r

h

a = 128°

r = 0.76n = 5

p=.05*

Group A Group B

p=.001*

Group comparisons are possible, but not requiredGroup comparisons are possible, but not required

Syndemic Orientation

Expanding Prevention ScienceExpanding Prevention Science“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 inContext

EcologicalThinking

Conditions

Ca

us

al

Ma

pp

ing

TimeDynamicModeling

Freedoms

Na

vig

ati

on

al

Va

lue

s

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.

“We cannot predict history but we can make it; and we can make evolution. More: we cannot avoid making evolution.

Every reform deliberately instituted in the structure of society changes both history and the selective forces that affect evolution — though evolutionary change may be the farthest thing from our minds as reformers. We are not free to avoid producing evolution: we are only free to close our

eyes to what we are doing.”

“We cannot predict history but we can make it; and we can make evolution. More: we cannot avoid making evolution.

Every reform deliberately instituted in the structure of society changes both history and the selective forces that affect evolution — though evolutionary change may be the farthest thing from our minds as reformers. We are not free to avoid producing evolution: we are only free to close our

eyes to what we are doing.”

-- Garrett Hardin-- Garrett Hardin

Creating a Safer Healthier FutureCreating a Safer Healthier Future

ImplicationsImplications

Systems view balances holism and precision

Complements a conventional categorical approach

Builds upon established theories and methods

Fosters essential partnerships (within public health; across sectors; between public and professionals)

Addresses planning and evaluation challenges

Advances a specific course of social change, one focused on assuring the conditions for health for all

Systems view balances holism and precision

Complements a conventional categorical approach

Builds upon established theories and methods

Fosters essential partnerships (within public health; across sectors; between public and professionals)

Addresses planning and evaluation challenges

Advances a specific course of social change, one focused on assuring the conditions for health for all

“We are as confused as ever, but on a higher level and about more important things.”

-- Anonymous

“We are as confused as ever, but on a higher level and about more important things.”

-- Anonymous

Syndemic Network Members in the USSyndemic Network Members in the UShttp://www.cdc.gov/syndemicshttp://www.cdc.gov/syndemics

International• Argentina• Australia• Canada• France• Grenada• Portugal• Puerto Rico• Switzerland

International• Argentina• Australia• Canada• France• Grenada• Portugal• Puerto Rico• Switzerland

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


Toward a Syndemic View of Environmental Health Challenges Bobby Milstein NCEH Dialogue July 28, 2003...

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