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Syndemics Prevention Network Health System Dynamics Mapping the Drivers of Population Health, Vulnerability, and Affliction Work in Progress (June 27,

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Presentation on theme: "Syndemics Prevention Network Health System Dynamics Mapping the Drivers of Population Health, Vulnerability, and Affliction Work in Progress (June 27,"— Presentation transcript:

1 Syndemics Prevention Network Health System Dynamics Mapping the Drivers of Population Health, Vulnerability, and Affliction Work in Progress (June 27, 2006) Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention Atlanta, Georgia Jack Homer Homer Consulting Voorhees, NJ

2 Syndemics Prevention Network Public Health Effort Across the Chain Upstream Prevention and Protection Total  3% Downstream Care and Management Total  97%

3 Syndemics Prevention Network Health Protection as a Dynamic System Safer, Healthier People Becoming Safer and Healthier Becoming Vulnerable People Becoming Afflicted People without Complications Developing Complications Afflicted People with Complications Dying from complications 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? Presented to the CDC Futures Health Systems Workgroup; Atlanta, GA; December 3, 2003.

4 Syndemics Prevention Network Why focus on “affliction”?

5 Syndemics Prevention Network Focusing on Disease Prevention and Control Has Led to Major Achievements Rate if trend continued Peak Rate Actual Rate Age-adjusted Death Rate per 100,000 Population Year Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.

6 Syndemics Prevention Network Great Depression End of WW II Nonsmokers Rights Movement Begins 1st Surgeon General’s Report 1st Smoking- Cancer Concern Federal Cigarette Tax Doubles Broadcast Ad Ban Source: USDA; 1986 Surgeon General's Report Adult Per Capita Cigarette Consumption and Major Smoking-and-Health Events United States, Focusing on Disease Prevention and Control Has Led to Major Achievements

7 Syndemics Prevention Network 17% increase Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. Available at: But the Pictures Look Different When We Examine Summary Measures of Health (or Affliction)

8 Syndemics Prevention Network % increase Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. Accessed June 4, Available at: Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. [Dissertation]. Cincinnati, OH: Union Institute and University; April 11 draft, How? Why? Where? Who? What? Navigating Health Futures Questions Supported by System Dynamics Modeling

9 Syndemics Prevention Network Why Do We Do Public Health Work? What is the System Organized to Do? CDC Vision & Mission Healthy people, in a healthy world, through prevention To promote health and quality of life by preventing and controlling disease, injury, and disability CDC Vision & Mission Healthy people, in a healthy world, through prevention To promote health and quality of life by preventing and controlling disease, injury, and disability Institute of Medicine The purpose of public health is to fulfill society’s interest in assuring the conditions in which people can be healthy Institute of Medicine The purpose of public health is to fulfill society’s interest in assuring the conditions in which people can be healthy How we reconcile these two frames of reference will shape the possibilities for what we can accomplish in leading health system change. A systems approach understands that both perspectives exist in a dynamic relationship with each other.

10 Syndemics Prevention Network Toward a Balanced System of Health Protection Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, Jackson DJ, Valdesseri R, CDC Futures Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 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? Presented to the CDC Futures Health Systems Work Group; Atlanta, GA; December 3, “One major task that CDC is intending to address is balancing this portfolio of our health system so that there is much greater emphasis placed on health protection, on making sure that we invest the same kind of intense resources into keeping people healthier or helping them return to a state of health and low vulnerability as we do to disease care and end of life care." -- Julie Gerberding Safer Healthier People Vulnerable People Afflicted without Complications Afflicted with Complications Becoming vulnerable Becoming safer and healthier Becoming afflicted Developing complications Dying from complications Tertiary Prevention Secondary Prevention Primary Prevention Targeted Protection Adverse Living Conditions General Protection Society's Health Response Demand for response Public Work

11 Syndemics Prevention Network Balancing Two Major Areas of Emphasis Safer Healthier People Vulnerable People Afflicted without Complications Afflicted with Complications Becoming vulnerable Becoming safer and healthier Becoming afflicted Developing complications Dying from complications Adverse Living Conditions Society's Health Response Demand for response General Protection Targeted Protection Primary Prevention Secondary Prevention Tertiary Prevention Public Work 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 Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; October 7, 2005 (draft).

12 Syndemics Prevention Network “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 Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10): Beyond Obvious Morality, Why Place So Much Emphasis on Democracy and Social Justice?

13 Syndemics Prevention Network A More Detailed Dynamic Hypothesis Incorporating Public Strength

14 Syndemics Prevention Network Health System Dynamics Incorporating Public Strength Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

15 Syndemics Prevention Network Health System Dynamics Incorporating Public Strength Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

16 Syndemics Prevention Network Health System Dynamics Incorporating Public Strength Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

17 Syndemics Prevention Network Health System Dynamics Incorporating Public Strength Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

18 Syndemics Prevention Network An Even More Detailed Dynamic Hypothesis Incorporating Public vs. Professional Concern

19 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

20 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

21 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

22 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

23 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

24 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

25 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

26 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

27 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

28 Syndemics Prevention Network Health System Dynamics Incorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at

29 Syndemics Prevention Network Summary Why is it So Hard to Work Across the Whole System? Initial Observations Upstream work requires more public concern, which is less a reaction to the prevalence of disease as to the spread of vulnerability and affliction that over many years threaten everybody (think of economic decline, inadequate education, unsafe housing, sprawl, racism, environmental decay, etc.) Long before upstream threats become widely apparent, money and other resources have focused downstream (where professional expertise and the weight of scientific evidence lie) Because of their role as providers of downstream services, health professionals do not respond to vulnerability and social disparity FOR ITS OWN SAKE, in the WAY that ordinary citizens often do Upstream health action involves broad-based organizing; it is political—but non- partisan—and cannot be done by professionals alone.

30 Syndemics Prevention Network Putting the System in Motion Prototype of a Simulation Game

31 Syndemics Prevention Network Neighborhood Assistance Game Homer J, Milstein B. Syndemic simulation. Forio Business Simulations, Available at.

32 Syndemics Prevention Network Neighborhood Assistance Game See also: Homer J, Milstein B. Syndemic simulation. Forio Business Simulations, Available at.


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