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Health System Dynamics

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

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

3 Health Protection as a Dynamic System
Safer, Healthier People Becoming Safer and Healthier Becoming Vulnerable Vulnerable People Becoming Afflicted Afflicted People without Complications Developing 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 Why focus on “affliction”?
Instead, use a small double loop model as example

5 Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998
Focusing on Disease Prevention and Control Has Led to Major Achievements Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 700 Rate if trend continued 600 500 Peak Rate 400 Age-adjusted Death Rate per 100,000 Population 300 200 Actual Rate CHD accounted for 460,000 deaths in It would have accounted for 1,144,000 if the rate had remained at its 1963 peak. 100 50 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year 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 Focusing on Disease Prevention and Control Has Led to Major Achievements
Adult Per Capita Cigarette Consumption and Major Smoking-and-Health Events United States, 1st Surgeon General’s Report Broadcast Ad Ban End of WW II Federal Cigarette Tax Doubles 1st Smoking- Cancer Concern Nonsmokers Rights Movement Begins Great Depression Source: USDA; 1986 Surgeon General's Report

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

8 Navigating Health Futures Questions Supported by System Dynamics Modeling
What? Where? 17% increase How? Why? Who? 2005 2025 2050 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, 2006.

9 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 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. CDC's Vision for the 21st Century Healthy People in a Healthy World – Through Prevention At CDC, we work hard to make people safer and healthier. By charting decisive courses of action, collecting the right information, and working closely with other health and community organizations, CDC has been putting science into action to tackle important health problems since With more than 8,500 employees across the country, CDC plays a critical role in protecting the public from the most widespread, deadly and mysterious threats against our health today and tomorrow. TO TOP CDC's Mission To promote health and quality of life by preventing and controlling disease, injury, and disability. CDC seeks to accomplish its mission by working with partners throughout the nation and world to monitor health, detect and investigate health problems, conduct research to enhance prevention, develop and advocate sound public health policies, implement prevention strategies, promote healthy behaviors, foster safe and healthful environments, and provide leadership and training. CDC has developed and sustained many vital partnerships with public and private entities that improve service to the American people. In FY 2000, the workforce of CDC comprised approximately 8,500 FTE in 170 disciplines with a public health focus. Although CDC's national headquarters is in Atlanta, Georgia, more than 2,000 CDC employees work at other locations, including 47 state health departments. Approximately 120 are assigned overseas in 45 countries. CDC includes 12 Centers, Institutes, and Offices.

10 Toward a Balanced System of Health Protection
Public Work Toward a Balanced System of Health Protection Society's Health Response Demand for response Adverse Living Conditions General Protection Tertiary Prevention Targeted Protection Primary Prevention Secondary Prevention Becoming safer and healthier Safer Afflicted Vulnerable Afflicted with Healthier without People Complications People Becoming Becoming Complications Developing vulnerable afflicted complications Dying from complications “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.” – From: World Health Organization. Health promotion glossary. World Health Organization, Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>. Adverse conditions could include any circumstances that inhibit people's freedom to live and develop their full potential. They include any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection). Phenomena like hunger, war, environmental decay, homelessness, illiteracy, and various forms of injustice are all examples of adverse living conditions. Dr. Gerberding uses this graphic to define how CDC is reorienting its work to achieve greater health impact. On April 19, 2004 this is how she described what CDC and its partners are attempting to do in leading change toward a more balanced portfolio of action throughout the health system. “I wanted to remind people of this diagram which emerged out of the Health Systems Working Group and let me just explain it since it may not be quite visible to you. The four boxes across the bottom really are the continuum of health, starting on the far left-hand side of the graph which is where people are healthy and not vulnerable. The next box being where they are vulnerable, they have a risk or a social situation that makes them vulnerable to diseases. Then the people who have the disease, not necessarily the complications. And then finally the people who are sick and have the complications. And if you notice the relative size of the orange arrows in this picture, in our country we still put a huge amount of emphasis on the right-hand side of this slide, about 97 percent of all of our dollars spent on health flow into the system, into these right-hand compartments, and very little emphasis is put over here on the left-hand side. I think one of the overarching themes of the Futures Initiative is driving us more to the left-hand side, not abandoning the good work we do in some of these other areas, but trying to work even harder to keep our population as far to the left side of this graph as we possibly can. What that really means is creating a future state which has a more balanced portfolio, and really taking CDC's efforts and investments and making sure that we are focusing on keeping people healthy, or if they're vulnerable to a problem, trying to do whatever we can to help them return to a state where they have less risk of acquiring diseases. “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 Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. 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, 2004. 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, 2003.

11 Balancing Two Major Areas of Emphasis
Safer Healthier People Vulnerable Afflicted without Complications Afflicted with Becoming vulnerable Becoming safer and healthier afflicted Developing complications Dying from Adverse Living Conditions Society's Health Response Demand for response General Protection Targeted Primary Prevention Secondary Tertiary Public Work 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 Healthy Public Policy & Public Work DEMOCRATIC SELF-GOVERNANCE World of Providing… Education Screening Disease management Pharmaceuticals Clinical services Physical and financial access Etc… Medical and Public Health Policy DISEASE AND RISK MANAGEMENT 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 Beyond Obvious Morality, Why Place So Much Emphasis on Democracy and 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 What do you suppose he means by.. … Internal crisis? --- Provincial – how so? --- Short term – in what sense? --- Social justice – how exactly does that figure into public health? Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):

13 A More Detailed Dynamic Hypothesis Incorporating Public Strength

14 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 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 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 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 An Even More Detailed Dynamic Hypothesis Incorporating Public vs
An Even More Detailed Dynamic Hypothesis Incorporating Public vs. Professional Concern

19 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 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 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 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 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 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 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 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 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 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 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. Upstream work requires more public concern and citizen organizing than downstream work Public concern isn't so much a reaction to the prevalence of disease as it is to the spread of disease and vulnerability that over many years ends up threatening everybody in a community (think of economic decline, inadequate housing, sprawl, racism, environmental decay, etc.) Long before those threats become widely apparent, the health professionals have taken the initiative by focusing money and other resources on affliction management (where their expertise and the weight of scientific evidence lie) and, perhaps unintentionally, excluded those citizen leaders who might have rallied the public to the cause of upstream prevention and protection. Because of their special role in providing downstream services, health professionals are not as concerned about vulnerability and social disparity FOR ITS OWN SAKE, in the WAY that ordinary citizens often are The effort required to do upstream prevention/protection is rightfully understood as public work (i.e., the work of citizens organizing themselves, individually and in groups, to transform their shared living and working conditions) Upstream public health action involves broad-based democratic organizing; it is non-partisan and cannot be done by health professionals alone Long before upstream threats become widely apparent, money and other resources have focused downstream (where professional expertise and the weight of scientific evidence lie) and, perhaps unintentionally, excluded those citizen leaders who might have rallied the public to the cause of upstream prevention and protection.

30 Putting the System in Motion Prototype of a Simulation Game
Instead, use a small double loop model as example

31 Neighborhood Assistance Game http://broadcast. forio
Homer J, Milstein B. Syndemic simulation. Forio Business Simulations, Available at <http://broadcast.forio.com/sims/syndemic2003/>.

32 Neighborhood Assistance Game
See also: Homer J, Milstein B. Syndemic simulation. Forio Business Simulations, Available at <http://broadcast.forio.com/sims/syndemic2003/>.


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