1. Syndemics Prevention Network Navigating Health Futures in a Dynamic and Democratic World Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics University of Auckland School of Population Health New Zealand Ministry of Health Auckland: September 12-14, 2007 Wellington: September 19-21, 2007

2. Syndemics Prevention Network Topics for Today Principles of a Syndemic Orientation A Navigational View of Public Health Work Dealing with Dynamic Complexity –Policy resistance –Boundary critique –Crafting high-leverage interventions –Causal mapping and simulation modeling –Building power Illustrations –North Karelia Project –CDC Diabesity Modeling –Industrial Areas Foundation Questions and Discussion Throughout

3. Syndemics Prevention Network Common Diverse Interconnected Increasing Costly Debilitating Deadly Inequitably distributed Largely preventable Chronic Conditions Here (and Everywhere) Are… Defy quick fixes and require a sound system-wide strategy to protect health as well as other values

4. Syndemics Prevention Network “Public health is probably the most successful system of science and technology combined, as well as social policy, that has ever been devised…It is, I think, a paradigmatic model for how you do concerned, humane, directed science.” -- Richard Rhodes Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002. How to Meet the Challenge? How is it directed? How are innovators approaching the challenge of assuring more healthful and equitable conditions?

5. 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 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

6. Syndemics Prevention Network Epi·demic The term epidemic is an ancient word signifying a kind of relationship wherein something is put upon the people Epidemiology first appeared just over a century ago (in 1873), in the title of J.P. Parkin's book "Epidemiology, or the Remote Cause of Epidemic Diseases“ Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972. Martin PM, Martin-Granel E. 2,500-year evolution of the term epidemic. Emerging Infectious Diseases 2006. Available from http://www.cdc.gov/ncidod/EID/vol12no06/05-1263.htm National Institutes of Health. A Short History of the National Institutes of Health. Bethesda, MD: 2006. Available from http://history.nih.gov/exhibits/history/ Parkin J. Epidemiology; or the remote cause of epidemic diseases in the animal and the vegetable creation. London: J and A Churchill, 1873. A representation of the cholera epidemic of the nineteenth century. Source: NIH “The pioneers of public health did not change nature, or men, but adjusted the active relationship of men to certain aspects of nature so that the relationship became one of watchful and healthy respect.” -- Gil Elliot

7. Syndemics Prevention Network Syn·demic The term syndemic, first used in 1992, strips away the idea that illnesses originate from extraordinary or supernatural forces and places the responsibility for affliction squarely within the public arena It acknowledges relationships and signals a commitment to studying population health as a a fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways Confounding Connecting* Synergism Syndemic Events System Co-occurring * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

8. Syndemics Prevention Network Time Series Models Describe trends Multivariate Stat Models Identify historical trend drivers and correlates Patterns Structure Events Increasing: Depth of causal theory Robustness for longer- term projection Value for developing policy insights Degrees of uncertainty Increasing: Depth of causal theory Robustness for longer- term projection Value for developing policy insights Degrees of uncertainty Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals Tools for Policy Planning & Evaluation

9. Syndemics Prevention Network Seeing Syndemics A syndemic orientation clarifies the dynamic and democratic character of public health work Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying Studying innovations in public health work, with emphasis on transformations in concepts, methods, and moral orientations The word syndemic signals special concern for many kinds of relationships: –mutually reinforcing health problems –health status and living conditions –synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens) Health Living Conditions Power to Act “Health Policy” “Social Policy” “Citizen- ship” It is one of a few approaches that explicitly includes within it our power to respond, along with an understanding of its changing pressures, constraints, and consequences

10. Syndemics Prevention Network Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004. Working Definition Syndemic Orientation A way of thinking about public health work that focuses on connections among health-related problems, considers those connections when developing health policies, and aligns with other avenues of social change to assure the conditions in which all people can be healthy Complements single-issue prevention strategies, which can be effective for discrete problems but often are mismatched to the goal of assuring conditions for health in its widest sense Incorporates 21 st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored.

11. 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., ?) Single disease, single cause (e.g., ?) Single disease, multiple causes (e.g., ?) Single cause, multiple diseases (e.g., ?) Multiple causes, multiple diseases (but no feedback dynamics) (e.g., ?) Dynamic feedback among afflictions, living conditions, and public strength (e.g., ?) 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.

12. Syndemics Prevention Network Exposes the Dynamic and Democratic Dimensions of 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?

13. Syndemics Prevention Network 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.” -- Clement Bezold Seeing Beyond the Probable

14. Syndemics Prevention Network Re-Directing the Course of Change Questions of Social Navigation Prevalence of Diagnosed Diabetes, United States 0 10 20 30 40 19801990200020102020203020402050 Million people Historical Data Markov Model Constants Incidence rates (%/yr) Death rates (%/yr) Diagnosed fractions (Based on year 2000 data, per demographic segment) Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164. Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494. Markov Forecasting Model Trend is not destiny! How? Why? Where? Who? What?

15. Syndemics Prevention Network Reconnecting with a Voyaging Tradition -- Polynesian Voyaging Society “Nainoa Thompson, who studied under Mau Pialug, became the first Hawaiian navigator in over 500 years to guide a canoe over this traditional route without instruments.”

16. Syndemics Prevention Network A Navigational View of Public Health Work Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006. Where we want to go? How do we prepare to get there? Where do you want your children to live? Where you do want to live?

17. Syndemics Prevention Network A Navigational View of Public Health Work "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. It was the most uncomfortable moment of silence that I can remember…That was the defining moment for me. I recognized that I have to participate in answering that question otherwise I am not taking responsibility for the place I love and the people I love.” -- Nainoa Thompson Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at.

18. Syndemics Prevention Network A Navigational View of Public Health Work "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. It was the most uncomfortable moment of silence that I can remember…That was the defining moment for me. I recognized that I have to participate in answering that question otherwise I am not taking responsibility for the place I love and the people I love.” -- Nainoa Thompson Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at.

19. Syndemics Prevention Network Foundations of Directed Change Science Conscience Consciousness Scire, to know FactsEffectsSelf KnowledgeMoralityPower

20. Syndemics Prevention Network Chronic Conditions are Classic Examples of Dynamically Complex Problems Differences between short- and long-term consequences of an action Time delays (e.g., developmental period, time to detect, time to respond) Accumulations (e.g., prevalences, resources, attitudes) Behavioral feedback (e.g., reactions by various actors) Nonlinear causal relationships (e.g., threshold effects, saturation effects) Differences or inconsistencies in goals/values among stakeholders Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458.

21. Syndemics Prevention Network Broad Dynamics of the Health Protection Enterprise Prevalence of Vulnerability, Risk, or Disease Time Health Protection Efforts - B Responses to Growth Resources & Resistance - B Obstacles Broader Benefits & Supporters R Reinforcers Potential Threats To understand and govern health trajectories over time, our concepts and methods for policy analysis must encompass the basic features of this dynamic and democratic system Size of the Safer, Healthier Population - Prevalence of Vulnerability, Risk, or Disease B Taking the Toll 0% 100% R Drivers of Growth Values for Health & Equity

22. Syndemics Prevention Network What Do These Observations Having in Common? Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68. Low tar and low nicotine cigarettes Lead to greater carcinogen intake Fad diets Produce diet failure and weight gain Road building to ease congestion Attracts development, increases traffic, delays, pollution, and urban sprawl Antibiotic & pesticide use Stimulate resistant strains Air-conditioning use Raises neighborhood heat Forest fire suppression Builds deadwood fueling larger, hotter, more dangerous fires War on drugs Raises price and attracts supply Suppressing dissent Inspires radicalization and extremism

23. Syndemics Prevention Network Policy Resistance is… “The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.” Meadows DH, Richardson J, Bruckmann G. Groping in the Dark: The First Decade of Global Modelling. Wiley: New York, 1985. -- Meadows, Richardson & Bruckmann Defining Keywords

24. Syndemics Prevention Network Systems Archetype “Fixes that Fail” Kim DH. Systems archetypes at a glance. Cambridge, MA: Pegasus Communications, Inc., 1994. Fix + Problem Symptom - Unintended Consequence + Delay + - B + R Characteristic Behavior: Better before Worse

25. Syndemics Prevention Network “Fixes that Fail” in Public Health Vocabulary The Risk of Targeted Interventions + Health Problem - - Exclusions + + Targeted Response B Delay + R What issues tend to be excluded?

26. Syndemics Prevention Network Some Categories of Exclusions Conceptual Social Organizational Political Disarray Disorientation Disparity & Disconnection Together, these forces may seriously undermine the effectiveness of health protection policy

27. Syndemics Prevention Network Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521. How Many Triangles Do You See?

28. 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 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

29. Syndemics Prevention Network The Weight of Boundary Judgments Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68. Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at. Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

30. Syndemics Prevention Network Implications for Policy Planning and Evaluation Insights from the Overview Effect Maintain a particular analytic distance Not too close to the details of service delivery, but not too far as to miss the internal pressures of vulnerability, capacity, and health status Potential to explain temporal patterns (e.g., better before worse) Structure determines behavior Potential to avoid scapegoating Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. Richmond B. Systems thinking: critical thinking skills for the 1990s and beyond. System Dynamics Review 1993;9(2):113-134. Available at. White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

31. Syndemics Prevention Network Seeking High-Leverage Policies Wall painting in the Stanzino delle Matematiche in the Galleria degli Uffizi (Florence, Italy). Painted by Giulio Parigi in the years 1599-1600. “Give me a firm place to stand and I will move the earth.” -- Archimedes Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at.

32. Syndemics Prevention Network Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995. National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at. Navigational Ventures Finland’s North Karelia Project

33. Syndemics Prevention Network Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995 Focusing the Intervention Policy Policy A: Focus on High Risk Individuals Policy B: Focus on Risk Conditions for All

34. Syndemics Prevention Network Broad Intervention Policy North Karelia Project Disease Burden Individual Effort Public Work Adapted from Puska P. North Karelia International Visitors’ Programme, 2003. Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at.

35. Syndemics Prevention Network Directing Change North Karelia Project Selected Action Strategies Medical services, if necessary Newspaper coverage: articles, editorials, letters TV time: highly rated 30-45 minute shows (no PSAs) Housewives’ organization: cooking and dietary choices Opinion leaders: role models, support groups, public action Tax shifting: tobacco, butter, milk Economic Renewal –Decline of dairy –Rise of berry –Rise of vegetable oil and rapeseed oil –Rise of healthier breads, cheeses, sausages, etc Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995.

36. Syndemics Prevention Network Transforming All Dimensions of the System Health Living Conditions Power to Act Efforts to Fight Afflictions Efforts to Improve Adverse Living Conditions Efforts to Build Power

37. Syndemics Prevention Network Efforts to Fight Afflictions (design/deliver) Screening Education Risk reduction counseling Medical/pharmaceutical treatment Disease self-management Directing Change North Karelia Project

38. Syndemics Prevention Network Efforts to Improve Adverse Living Conditions (develop/promote) Tobacco legislation Food-labeling requirements Margarines and oils Low-fat milk Low-fat, low-salt, high-fiber bread Vegetable-containing sausage (with mushrooms) Berry farming and consumption Community competitions, morale, and social norms State welfare system (at the national, regional, sub-regional, and local levels) Directing Change North Karelia Project

39. Syndemics Prevention Network Health Professionals Physicians Health Educators Psychologists Epidemiologists Sociologists Hospital administrators Pharmaceutical manufacturers Nurses Rehabilitation therapists Other Citizens Bakers Farmers Grocers Food scientists, manufacturers Restaurant owners Housewives Entertainers Entrepreneurs Journalists, media professionals Teachers School administrators Elected representatives Building Power North Karelia Project

40. Syndemics Prevention Network Charting Progress North Karelia Project Vartiainen E, Puska P, Pekkanen J, Toumilehto J, Jousilahti P. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. British Medical Journal 1994;309(6946):23-27.

41. Syndemics Prevention Network -49% -68% -73% -44% -71% Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995. National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Accessed May 30, 2004 at. Charting Progress North Karelia Project

42. Syndemics Prevention Network Framing the Challenge of Chronic Illness PERSON People living with affliction PLACE Areas with a recurring problem of affliction TIME People vulnerable to affliction Health States & Rates

43. Syndemics Prevention Network 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? CDC Futures Health Systems Workgroup; Atlanta, GA; 2003. Tertiary Prevention Secondary Prevention Primary Prevention Targeted Protection Society's Health Response Demand for response Public Work Safer Healthier People Becoming vulnerable Becoming safer and healthier Vulnerable People Becoming afflicted Afflicted without Complications Developing complications Afflicted with Complications Dying from complications Health System Dynamics Adverse Living Conditions General Protection 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? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Gerberding JL. FY 2008 CDC Congressional Budget Hearing. Testimony before the Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, United States House of Representatives; Washington, DC; March 9, 2007. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458. “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

44. 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 MANAGEMENT OF DISEASES AND RISKS 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. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.

45. Syndemics Prevention Network Seeing Conditions as Freedoms Adverse living conditions are circumstances that inhibit people's freedom to be safe and healthy and develop their full potential They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection) Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions 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 http://www.cdc.gov/syndemics

46. Syndemics Prevention Network Choice and Non-Choice Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93. “Choices are always made from among alternatives presented by the social environment, or by circumstances that were themselves not chosen…When we recognize the elements of non-choice in choice, we can escape the contradiction between social causation and individual responsibility and understand the interactiveness of the two.”

47. Syndemics Prevention Network Understanding Health as Public Work 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 - Vulnerable and Afflicted People Fraction of Adversity, Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) - Public Strength Citizen Involvement in Public Life Social Division

48. Syndemics Prevention Network Evaluating Dynamic, Democratic Policies How can we learn about the consequences of alternative policies in a system of this kind?

49. Syndemics Prevention Network System Dynamics Was Developed to Address Problems Marked By Dynamic Complexity Good at Capturing Differences between short- and long-term consequences of an action Time delays (e.g., incubation period, time to detect, time to respond) Accumulations (e.g., prevalences, resources, attitudes) Behavioral feedback (reactions by various actors) Nonlinear causal relationships (e.g., threshold effects, saturation effects) Differences or inconsistencies in goals/values among stakeholders Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458. Origins Jay Forrester, MIT, Industrial Dynamics, 1961 (“One of the seminal books of the last 20 years.”-- NY Times) Public policy applications starting late 1960s Population health applications starting mid-1970s

50. Syndemics Prevention Network Learning In and About Dynamic Systems Unknown structure Dynamic complexity Time delays Impossible experiments Real World Information Feedback Decisions Mental Models Strategy, Structure, Decision Rules Selected Missing Delayed Biased Ambiguous Implementation Game playing Inconsistency Short term Misperceptions Unscientific Biases Defensiveness Inability to infer dynamics from mental models Known structure Controlled experiments Enhanced learning Virtual World Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330. Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

51. 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

52. Syndemics Prevention Network Selected CDC Projects Featuring System Dynamics Modeling Syndemics Mutually reinforcing afflictions Diabetes In an era of rising obesity Obesity Lifecourse consequences of changes in caloric balance Infant Health Fetal and infant morbidity/mortality Polio Reintroductions after eradication Heart Disease and Stroke Preventing and managing multiple risks, in context Milstein B, Homer J. Background on system dynamics simulation modeling, with a summary of major public health studies. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; February 1, 2005.. Grantmaking Scenarios Timing and sequence of outside assistance Upstream-Downstream Effort Balancing disease treatment with prevention/protection Healthcare Reform Relationships among cost, quality, equity, and health status

53. Syndemics Prevention Network Simulations for Learning in Dynamic 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 Dialogue Dynamic Hypothesis (Causal Structure)Plausible Futures (Policy Experiments) Obese fraction of Adults (Ages 20-74) 0% 10% 20% 30% 40% 50% 197019801990200020102020203020402050 Fraction of popn 20-74

54. Syndemics Prevention Network Model Uses and Audiences Set Better Goals (Planners & Evaluators) –Identify what is likely and what is plausible –Estimate intervention impact time profiles –Evaluate resource needs for meeting goals Support Better Action (Policymakers) –Explore ways of combining policies for better results –Evaluate cost-effectiveness over extended time periods –Increase policymakers’ motivation to act differently Develop Better Theory and Estimates (Researchers) –Integrate and reconcile diverse data sources –Identify causal mechanisms driving system behavior –Improve estimates of hard-to-measure or “hidden” variables

55. Syndemics Prevention Network CDC Diabetes System Modeling Project Discovering Stock-Flow Dynamics Through Action Labs Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.

56. Syndemics Prevention Network CDC Diabetes System Modeling Project Diabetes programs face tough challenges and questions –With rapid growth in prevalence, is improved control good enough? –Studies show primary prevention is possible, but how much impact in practice and at what cost? –How best to balance interventions? Model developed with program planners, diabetes researchers, and epidemiologists Model-based “learning lab” workshops for planners—federal, state, and local Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494. Done in conjunction with Sustainability Institute and the Center for Public Health Practice at Emory University

57. Syndemics Prevention Network Health Care & Public Health Agency Capacity Provider supply Provider understanding, competence Provider location System integration Cost of care Insurance coverage Population Flows We Convened a Model-Scoping Group of 45 CDC professionals and epidemiologists in December 2003 to Explore the Full Range of Forces Driving Diabetes Behavior over Time Personal Capacity Understanding Motivation Social support Literacy Physio-cognitive function Life stages Metabolic Stressors Nutrition Physical activity Stress Baseline Flows Health Care Utilization Ability to use care (match of patients and providers, language, culture) Openness to/fear of screening Self-management, monitoring Percent of patients screened Percent of people with diabetes under control Civic Participation Social cohesion Responsibility for others Forces Outside the Community Macroeconomy, employment Food supply Advertising, media National health care Racism Transportation policies Voluntary health orgs Professional assns University programs National coalitions Local Living Conditions Availability of good/bad food Availability of phys activity Comm norms, culture (e.g., responses to racism, acculturation) Safety Income Transportation Housing Education

58. Syndemics Prevention Network Inflow Volume Outflow Developing Burden of Diabetes Total Prevalence (people with diabetes) Unhealthy Days (per person with diabetes) Costs (per person with diabetes) People with Diagnosed Diabetes Diagnosis Deaths a b People with Prediabetes Developing Diabetes Onset c d People with Normal Blood Sugar Levels Prediabetes Onset Recovering from Prediabetes e Diabetes Management Diabetes Detection Obesity in the General Population Prediabetes Detection & Management People with Undiagnosed Diabetes Deaths Overview of Diabetes Stock-and-Flow Model

59. Syndemics Prevention Network Overview of Diabetes Stock-and-Flow Model Inflow Volume Outflow Developing Burden of Diabetes Total Prevalence (people with diabetes) Unhealthy Days (per person with diabetes) Costs (per person with diabetes) People with Diagnosed Diabetes Diagnosis Deaths a b People with Prediabetes Developing Diabetes Onset c d People with Normal Blood Sugar Levels PreDiabetes Onset Recovering from PreDiabetes e Diabetes Management Diabetes Detection Obesity in the General Population Prediabetes Detection & Management People with Undiagnosed Diabetes Deaths Standard boundary This larger view takes us beyond standard epidemiological models and most intervention programs

60. Syndemics Prevention Network Using Available Data to Ground the Model Information SourcesData U.S. Census Population growth and death rates Fractions elderly, black, hispanic Health insurance coverage National Health Interview Survey Diabetes prevalence Diabetes detection National Health and Nutrition Examination Survey Prediabetes prevalence Obesity prevalence Behavioral Risk Factor Surveillance System Eye exam and foot exam Taking diabetes medications Unhealthy days (HRQOL) Professional Literature Effects of risk factors and mgmt on onset, complications, and costs Direct and indirect costs of diabetes

61. Syndemics Prevention Network One way we establish the model’s value is by looking at its ability to reproduce historical data (2 variables out of 10 such comparisons) Diagnosed diabetes per thousand total popn 60 45 30 15 0 1980198419881992199620002004 Model NHIS Model Diagnosed fraction of diabetes popn 1 0.8 0.6 0.4 1980198419881992199620002004 NHANES III NH ’99 -’00 NH II Homer J. Reference guide for the CDC Diabetes System Model. Atlanta, GA: Division of Diabetes Translation, Centers for Disease Control and Prevention; August, 2006..

62. Syndemics Prevention Network Healthy People 2010 Diabetes Objectives: What Can We Accomplish? -11%7.8 8.8 per 1,000 Reduce Diabetes–related Deaths Among Diagnosed (5-6) -38%25 40 per 1,000 Reduce Prevalence of Diagnosed Diabetes (5-3) -29%2.5 3.5 per 1,000 Reduce New Cases of Diabetes (5-2) Increase Diabetes Diagnosis (5-4) +18%80%68% Percent Change HP 2010 Target Baseline U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm

63. Syndemics Prevention Network A History of Missed Goals Simulations have helped diabetes planners set more realistic goals. Milstein B, Jones A, Homer J, Murphy D, Essien J, Seville D. Charting plausible futures for diabetes prevalence: A role for system dynamics simulation modeling. Preventing Chronic Disease July 2007. 20 30 40 50 60 1980198519901995200020052010 Time (Years) People with Diagnosed Diabetes per 1,000 Popn HP 2000 prevalence goal HP 2010 prevalence goal Status quo (simulated) +33% -11% -38% Diagnosed Diabetes Prevalence per Thousand Adults Meet HP2010 detection goal Meet HP2010 onset goal Surveillance data (NHIS) +25%

64. Syndemics Prevention Network Connecting the Objectives Population Flows and Dynamic Accounting 101 It is impossible for any policy to reduce prevalence 38% by 2010! People with Undiagnosed Diabetes People with Diagnosed Diabetes Dying from Diabetes Complications Diagnosed Onset Initial Onset People without Diabetes As would stepped-up detection effort Reduced death would add further to prevalence With a diagnosed onset flow of 1.1 mill/yr And a death flow of 0.5 mill/yr (4%/yr rate) The targeted 29% reduction in diagnosed onset can only slow the growth in prevalence Milstein B, Jones A, Homer J, Murphy D, Essien J, Seville D. Charting plausible futures for diabetes prevalence: A role for system dynamics simulation modeling. Preventing Chronic Disease July 2007.

65. Syndemics Prevention Network Monthly Unhealthy Days from Diabetes per Thousand Policy Testing…and Reason for Hope With a combination of improved control and aggressive primary prevention, growth in the burden of diabetes could be limited for the next 10 years and for decades beyond. U.S. Morbidity from Diabetes Simulated 1980-2050 600 500 400 300 200 19801990200020102020203020402050 Combination Primary prevention Base Control

66. Syndemics Prevention Network The Modeling Process is Having an Impact Budget for primary prevention was doubled –from meager to modest HP2010 prevalence goal has been modified –from a large reduction to no change (but still not an increase) Research, program, and policy staff are working more closely –Many new leaders emerging, but truly cross-functional teams are still forming State health departments and their partners are now engaged –initial efforts in 13 states

67. 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 People in Places Boundary Critique Governing Dynamics Causal Mapping Plausible Futures Dynamic Modeling Navigational Freedoms Democratic Public Work

68. 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 Power Has to be Organized Chambers ET, Cowan MA. Roots for radicals. New York: Continuum, 2003., p. 65.

69. Syndemics Prevention Network Growth of Citizen Leaders “Almost everyone knows about the explosion of the dot-coms…but millions have still not heard the big story: the worldwide explosion of dot-orgs. More people today have the freedom, time, wealth, health, exposure, social mobility, and confidence to address social problems in bold new ways.” -- David Bornstein Bornstein D. How to change the world: social entrepreneurs and the power of new ideas. New York: Oxford University Press, 2004. 60%

70. Syndemics Prevention Network Contrasting Strategies for Directing Social Change AdvocatingMobilizingOrganizing Definition Pleading in another’s behalf Assembling or coordinating for a purpose Arranging systematically for harmonious functioning or united action Form A voice A following A working whole Products Special interests Mass movements Public work In Practice Ad hoc Diminishing #s over time Weak accountability Weak commitment to institutional development Single, charismatic leader Weak ties to values and self-interests Enduring Increasing #s over time Strong accountability Strong commitment to institutional development Many leaders in many networks Strong ties to values and self-interests

71. Syndemics Prevention Network Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004.. Living wage Nehemiah Homes Alliance Schools Quest job training Blight removal Environmental cleanup After school programs Smaller high schools Organizing Power IAF Issue Campaigns

72. Syndemics Prevention Network Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004.. Broad-based, multi-issue orgs, built to win and built to last Power precedes programs Never do for others what they can do for themselves The world as it is vs. the world as it should be Act to get a specific reaction Public accountability begins with self-accountability No permanent allies, no permanent enemies Organize, disorganize, reorganize Organizing Power IAF Principles

73. Syndemics Prevention Network Organizing Power IAF Organizing Activities Have relational meetings Find and train leaders Recruit institutions and allies Pay dues Do research (problems, power, interests) Act on winnable issues Evaluate every action Organize, disorganize, reorganize Industrial Areas Foundation. About IAF. Industrial Areas Foundation, 2004..

74. Syndemics Prevention Network Revisiting our Hypothesis of Health System Dynamics Incorporating Public vs. Professional Concern

75. 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 http://www.cdc.gov/syndemics

76. 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 http://www.cdc.gov/syndemics

77. 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 http://www.cdc.gov/syndemics

78. 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 http://www.cdc.gov/syndemics

79. 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 http://www.cdc.gov/syndemics

80. 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 http://www.cdc.gov/syndemics

81. 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 http://www.cdc.gov/syndemics

82. 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 inequity 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.

83. Syndemics Prevention Network “I can see how connected the Māori are to their ancestry. And because they are connected to their past, I believe that it's much easier for them to see the kind of future they want to voyage to.” -- Nainoa Thompson Thompson N. The voyage of rediscovery: 1985-1987. Polynesian Voyaging Society, 2005. Available at. Voyage of Rediscovery Hawaii – Aotearoa, 1985-1987