1. Syndemics Prevention Network Beyond Methodolgoical Technique Systems Science in Service of Social Change Bobby Milstein Institute on Systems Science and Health Ann Arbor, MI May 3-8, 2009

2. Syndemics Prevention Network Troubling Extremes Over-reliance on ModelsUnder-reliance on Models

3. Syndemics Prevention Network Imperatives for Protecting Health Gerberding JL. Protecting health: the new research imperative. Journal of the American Medical Association 2005;294(11):1403-1406. Typical Current State “Static view of problems that are studied in isolation” Proposed Future State “Dynamic systems and syndemic approaches” “Currently, application of complex systems theories or syndemic science to health protection challenges is in its infancy.” -- Julie Gerberding

4. Syndemics Prevention Network A Growing Portfolio of CDC Efforts are Incorporating System Sciences (e.g., SNA, SD, ABM) Infection dynamics Smallpox, anthrax, HIV, STD, TB, polio, SARS, influenza, etc. Chronic diseases and risks Diabetes, obesity, hypertension, cardiovascular disease, oral health, tobacco, diet, physical activity, stress, alcohol, sleep, etc. Environmental health Air, water, soil, heat, climate change, etc. Preparedness Biological, radiological, chemical, environmental, etc. Violence and Injury Child maltreatment, sexual assault, etc. Grantmaking Scenarios Timing and sequence of outside assistance Upstream-Downstream Effort Balancing disease treatment with prevention/protection Health System Performance Relationships among cost, quality, equity, and health status

5. Syndemics Prevention Network Changing (and Accumulating) Views of Population Health What Accounts for Poor Population Health? God’s will Humors, miasma, ether Poor living conditions, immorality (e.g., sanitation) Single disease, single cause (e.g., germ theory) Single disease, multiple causes (e.g., heart disease) Single cause, multiple diseases (e.g., tobacco) Multiple causes, multiple diseases (but no feedback dynamics) (e.g., multi-causality) Dynamic feedback among afflictions, living conditions, and public strength (e.g., syndemic orientation) 1880 1950 1960 1980 2000 1840 Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006. Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

6. Syndemics Prevention Network Incorporating a Systems Orientation Into Public Health Work PUBLIC HEALTH WORK Innovative Health Ventures UNDERSTANDING CHANGE Systems Science What causes population health problems? How are efforts to protect the public’s health organized? How and when do health systems change (or resist change)? SETTING DIRECTION Public Health What are health leaders trying to accomplish? GOVERNING MOVEMENT Social Navigation Directing Change Charting Progress Who does the work? By what means? According to whose values? How are conditions changing? In which directions?

7. Syndemics Prevention Network Syndemic Orientation Expanding Public Health Science “Public health imagination involves using science to expand the boundaries of what is possible.” -- Michael Resnick Epidemic Orientation Problems/ Opportunities Among People in Places Over Time Boundary Critique Governing Dynamics Causal Mapping Plausible Futures Dynamic Modeling Navigational Freedoms Democratic Public Work

8. Syndemics Prevention Network Syndemic Orientation Network ViewDynamic View Navigational View Aligning Concepts and Methods ConnectionsLeverage Public Work, Civic Agency Proximity DataCausal Data Directional Data What links to what?What influences what? Where are we going?

9. Syndemics Prevention Network A Model Is… An inexact representation of the real thing They help us understand, explain, anticipate, and make decisions “All models are wrong, some are useful.” -- George Box “All models are wrong, some are useful.” -- George Box Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Available at Sterman J. A sketpic's guide to computer models. In: Barney GO, editor. Managing a Nation: the Microcomputer Software Catalog. Boulder, CO: Westview Press; 1991. p. 209-229.

10. Syndemics Prevention Network Ulrich W. Boundary critique. In: Daellenbach HG, Flood RL, editors. The Informed Student Guide to Management Science. London: Thomson; 2002. p. 41-42.. Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf Midgley G. The sacred and profane in critical systems thinking. Systems Practice 1992;5:5-16. Boundary Critique Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. -- Albert Einstein

11. Syndemics Prevention Network Boundary Critique Equalizing Experts and Ordinary Citizens “Professional expertise does not protect against the need for making boundary judgements…nor does it provide an objective basis for defining boundary judgements. It’s exactly the other way round: boundary judgements stand for the inevitable selectivity and thus partiality of our propositions. It follows that experts cannot justify their boundary judgements (as against those of ordinary citizens) by referring to an advantage of theoretical knowledge and expertise. When it comes to the problem of boundary judgements, experts have no natural advantage of competence over lay people.” Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247-268. -- Werner Ulrich

12. Syndemics Prevention Network Defining Keywords Crick BR. In defense of politics. 4th ed Chicago, IL: University of Chicago Press, 1993. Boyte HC. Everyday politics: reconnecting citizens and public life. Philadelphia, PA: University of Pennsylvania Press, 2004. Partisan Fervent, sometimes militant support for a party, cause, faction, person, or idea, from Middle French, part, “faction” Political The action of diverse people negotiating their differences for common governance, from the Greek, politikos, “of the citizen”

13. Syndemics Prevention Network Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective Practice 2000;1(2):247- 268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf Boundary Critique

14. Syndemics Prevention Network Conversations Around the Model are Critical What measures of improvement ought to be included? What else is missing? Who else is missing? What would be helpful to you? SYSTEM DYNAMICS MODEL Other chronic disease endpoints Downstream interventions and costs Local implementation opportunities Local implementation strengths and success Political will STRATEGIC DIALOGUE Implementation actions and costs Health inequities Local leadership capacity Ability to engage all stakeholders Borderline conditions

15. Syndemics Prevention Network Navigating Change in Dynamic and Democratic Systems Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000. Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. Multi-stakeholder Interactions Dynamic Hypothesis (Causal Structure)Plausible Futures (Policy Experiments)

16. Syndemics Prevention Network “Academics and pundits love to throw around the term ‘social capital’ and debate its nuances, but most of them couldn’t organize a block party.” -- Ed Chambers Beware of Superficial Understanding Chambers ET, Cowan MA. Roots for radicals. New York: Continuum, 2003., p. 65.

17. Syndemics Prevention Network Loose groupings of interested individuals don’t have a prayer of addressing major crises–housing, crime, schools, jobs, and others. Each crisis is, at bottom, a power crisis. The power of the mob, the power of drug lords, the power of corrupt borough machines, and the inertia of the police bureaucracy could only be challenged by another, deeper institutional power. -- Michael Gecan Power Has to be Organized Gecan M. Going public. Boston: Beacon Press, 2002.

18. Syndemics Prevention Network Is Anyone Really an Outsider? Boyte HC. Doctoral education for the 21st century: reframing scholarship in mass communications. Civic Engagement News 2004;5. Outside ExpertCitizen Actor Focus Efficiency of means Ask both why and how Discourse Technical Political (non-partisan) Stance Seeing from discipline From the world Goal Fix problem Create values Develop capacities Philosophy Positivism Pragmatism Key actor(s) Expert Citizens (each w/ own expertise) Skills Disaggregation, analysis Integration, anticipation, action

19. Syndemics Prevention Network Innovation, Pragmatism, and the Promise of “What If…” Thinking Shook J. The pragmatism cybrary. 2006. Available at. Addams J. Democracy and social ethics. Urbana, IL: University of Illinois Press, 2002. West C. The American evasion of philosophy: a genealogy of pragmatism. Madison, WI: University of Wisconsin Press, 1989. "Grant an idea or belief to be true…what concrete difference will its being true make in anyone's actual life? -- William James Pragmatism Begins with a response to a perplexity or injustice in the world Learning through action and reflection (even simulated action can be illuminating) Asks, “How does this work make a difference?” Positivism Begins with a theory about the world Learning through observation and falsification Asks, “Is this theory true?” These are conceptual, methodological, and moral orientations, which shape how we think, how we act, how we learn, and what we value