1. Possibilities for Better Integrating System Dynamics Into Public Health Bobby Milstein 21 st International Conference of the System Dynamics Society New York, 2003 Bobby Milstein 21 st International Conference of the System Dynamics Society New York, 2003

2. Seeing Beyond the Probable Possible What may happen? Plausible What could happen? Probable What will likely happen? Preferable What do we want to have happen? Possible What may happen? Plausible What could happen? Probable What will likely happen? Preferable What 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

3. Smallpox Eradication Our Greatest (Temporary) Victory

4. A Glimpse Into 2020 Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

5. Starting Assumptions Most public health agencies act as if each affliction can be prevented individually by understanding its unique causes and developing targeted interventions This compartmentalized approach is ingrained in financial structures, problem solving frameworks, statistical models, and criteria for professional prestige Most public health agencies act as if each affliction can be prevented individually by understanding its unique causes and developing targeted interventions This compartmentalized approach is ingrained in financial structures, problem solving frameworks, statistical models, and criteria for professional prestige

6. Need 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

7. Diseases of Disarray Hardening of the categories Tension headache between treatment and prevention Hypocommitment to training Cultural incompetence Political phobia Input obsession Hardening of the categories Tension headache between treatment and prevention Hypocommitment to training Cultural incompetence Political phobia Input obsession Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8. Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8. Wiesner PJ. Four disease of disarray in public health. Annals of Epidemiology. 1993;3(2):196-8. Chambers LW. The new public health: do local public health agencies need a booster (or organizational "fix") to combat the diseases of disarray? Canadian Journal of Public Health 1992;83(5):326-8.

8. Spectrum of Prevention SHORT months-years INTERMEDIATE years-decades LONG decades-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 Behavioral Change Focus on Risk Disease Prevention INTERGENERATIONAL Social Change Focus on Conditions Health Promotion Focus on Capacity for Action Capacity Building or Empowerment Infrastructural Change

9. Public Health Goals Are Accumulating and Becoming More Systemic 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

10. Virtually Unstoppable Trends in Prevention Science Systems-oriented Politically engaged Philosophically conscious Systems-oriented Politically engaged Philosophically conscious

11. What Is Not Happening Integration Dynamic hypotheses of health states and rates Testing through simulation Searching for polices that can be effective Rehearsing policy implementation Learning about dynamic complexity Integration Dynamic hypotheses of health states and rates Testing through simulation Searching for polices that can be effective Rehearsing policy implementation Learning about dynamic complexity

12. Brief History of Causal Theory What accounts for poor community health? God’s will Humors, miasma, ether Poor living conditions, immorality (sanitation) Single disease, single cause (germ theory) Single disease, multiple causes (heart disease) Single cause, multiple diseases (tobacco) Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology) Dynamic feedback among afflictions, living conditions, and 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

13. Cost-effectiveness analysis: simulating patterns of disease dynamics, prevention activities, and resources Program dynamics: simulating system-wide impacts of comprehensive programs with interacting components Community dynamics: simulating the mediating effects of local conditions, capabilities, and constraints Group model building: providing more structure and insight to the participatory planning process Game-based learning: improving intuition, foresight, commitment, and agility in navigating change Cost-effectiveness analysis: simulating patterns of disease dynamics, prevention activities, and resources Program dynamics: simulating system-wide impacts of comprehensive programs with interacting components Community dynamics: simulating the mediating effects of local conditions, capabilities, and constraints Group model building: providing more structure and insight to the participatory planning process Game-based learning: improving intuition, foresight, commitment, and agility in navigating change Roles for System Modeling in Public Health