1. Syndemics Prevention Network NIH Roadmap Methodology and Technology Summit Bethesda, MD August 21-22, 2006 Syndemic Thinking and Simulation Studies in Public Health Work Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc.gov Methodological Considerations in Interdisciplinary Health Behavior/Social Science Research

2. Syndemics Prevention Network Picture a Neighborhood Where… Conditions are not supportive of healthy living People are either afflicted by or at risk for numerous mutually reinforcing health problems Citizen leaders are making an effort to alleviate afflictions and improve living conditions, but their power is limited More could be done through local, broad-based organizing and with effective assistance from outside allies (e.g., philanthropy, government) James Nachtwey in Sachs J. How to end poverty. Time Magazine 2005 March 14. How does public health work typically proceed in such circumstances?

3. Syndemics Prevention Network Side Effects of Specialization Confusion, inefficiency, organizational disarray Competition for limited resources Attention to “local” causes, near in time and space Neglected feedback (+ and -) Confounded evaluations Coercive power dynamics Priority on a single value, implicitly or explicitly devaluing others Limited mandate to address context (living conditions) or infrastructure (public strength) Disappointing track record, especially with regard to inequalities A C B D E ABCD E Issue Organizations Neighborhood

4. Syndemics Prevention Network Diseases of Disarray 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.

5. Syndemics Prevention Network A Complementary Science of Relationships Efforts to Reduce Population Health Problems Problem, problem solver, response Efforts to Organize a System that Assures Healthful Conditions for All Dynamic interaction among multiple problems, problem solvers, and responses Institute of Medicine. The future of public health. Washington, DC: National Academy Press, 1988. Institute of Medicine. The future of the public's health in the 21th century. Washington, DC: National Academy Press, 2002. Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003. True innovation occurs when things are put together for the first time that had been separate. – Arthur Koestler

6. Syndemics Prevention Network Highlights 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?

7. Syndemics Prevention Network New Word for a Familiar Phenomenon Singer M, Snipes C. Generations of suffering: experiences of a treatment program for substance abuse during pregnancy. Journal of Health Care for the Poor and Underserved 1992;3(1):222-34. Singer M. 1994. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Social Science and Medicine 39(7): 931-948. Singer M. 1996. A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology 24(2): 99-110. Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly 2003;17(4):423-441. “We have introduced the term ‘syndemic’ to refer to the set of synergistic or intertwined and mutually enhancing health and social problems facing the urban poor. Violence, substance abuse, and AIDS, in this sense, are not concurrent in that they are not completely separable phenomena.” -- Merrill Singer What was Singer doing? How might this perspective transform public health science?

8. 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 “Experts cannot justify their boundary judgments by referring to an advantage of theoretical knowledge and expertise. When it comes to the problem of boundary judgments, experts have no natural advantage of competence over lay people.” -- Werner Ulrich

9. 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

10. 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

11. Syndemics Prevention Network Changing (and Accumulating) Ideas in Causal Theory 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-level modeling) Dynamic feedback among afflictions, living conditions, and public strength (e.g., syndemic orientation) 1880 1950 1960 1980 2000 1840 Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

12. Syndemics Prevention Network Seeing Syndemics 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) 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 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 Health Living Conditions Public Strength A syndemic orientation clarifies the dynamic and democratic character of public health work

13. Syndemics Prevention Network What Do These Observations Have in Common? Road building programs increase traffic, delays, and pollution Low tar and nicotine cigarettes increase carcinogen intake Antilock brakes cause some to drive more aggressively Forest fire suppression leads to larger, hotter, and more dangerous fires Flood control efforts lead to more severe floods and excess cost Antibiotics stimulate the evolution of drug-resistant pathogens Pesticides and herbicides stimulate the evolution of resistant pests and accumulate up the food chain to poison fish, birds, and humans Antiretroviral treatment reduces mortality among those with HIV, but has increased risky behaviors, causing a rebound in incidence Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514.

14. Syndemics Prevention Network Understanding Policy Resistance Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982. Merton RK. The unanticipated consequences of purposive social action. American Sociological Review 1936;1936:894-904. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68. Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself. -- Meadows, Richardson, Bruckman

15. Syndemics Prevention Network Misleading Framing Assumptions Focus on the events Everything that happens must have a cause That cause must be close in time and space –Instantaneous impacts –Causality runs one-way –Independence –Impacts are linear and constant Stepwise progress will lead to system wide improvement Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997. These assumptions overlook non-local forces of change, such as feedback, accumulation, delay, and non-linear response

16. Syndemics Prevention Network Matching Appropriate Concepts and Methods System Dynamics* Social Navigation* POLICY DEVELOPMENT ASSESSMENT ASSURANCE Network Analysis* Categorical Orientation Syndemic Orientation What causes what? (feedback data) What links to what? (proximity data) Where are we? Where are we going? (directional data) * Examples selected from a larger class of system-oriented techniques

17. Syndemics Prevention Network System Dynamics Was Designed to Address Problems Marked By Dynamic Complexity Good at Capturing Differences between short- and long-term consequences of an action Time delays (e.g., transitions, detection, response) Accumulations (e.g., prevalence, capacity) Behavioral feedback (e.g., actions trigger reactions) Nonlinear causal relationships (e.g., effect of X on Y is not constant) Differences or inconsistencies in goals/values among stakeholders Forrester JW. Industrial dynamics. Cambridge, MA: MIT Press, 1961. 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 (from late 1950s) Public policy applications starting late 1960s

18. 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 Degrees of uncertainty Robustness for longer- term projection Value for developing policy insights Increasing: Depth of causal theory Degrees of uncertainty Robustness for longer- term projection Value for developing policy insights Dynamic Simulation Models Anticipate new trends, learn about policy consequences, and set justifiable goals Tools for Policy Analysis

19. Syndemics Prevention Network Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. Barriers to Learning in Dynamic Systems

20. Syndemics Prevention Network But We Can Create Virtual Worlds for Learning Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. “In [dynamically complex] circumstances simulation becomes the only reliable way to test a hypothesis and evaluate the likely effects of policies." -- John Sterman

21. Syndemics Prevention Network Selected CDC Projects Featuring System Dynamics Modeling, 2001-2006 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 Hypertension Improving detection and control 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 neighborhood health investments Upstream-Downstream Effort Balancing disease treatment with prevention and protection Healthcare Reform Relationships among cost, quality, equity, and health status

22. Syndemics Prevention Network System Modeling Supports Navigational Policy Dialogues Prevalence of Diagnosed Diabetes, US 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 Simulation Experiments in Action Labs Trend is not destiny! How? Why? Where? Who? What?

23. 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. Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514. Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Multi-stakeholder Dialogue Dynamic Hypothesis (Causal Structure) “The future is not to be predicted, but created.” -- Arthur C. Clarke Plausible Futures (Policy Experiments)

24. Syndemics Prevention Network “Simulation is a third way of doing science. Like deduction, it starts with a set of explicit assumptions. But unlike deduction, it does not prove theorems. Instead, a simulation generates data that can be analyzed inductively. Unlike typical induction, however, the simulated data comes from a rigorously specified set of rules rather than direct measurement of the real world. While induction can be used to find patterns in data, and deduction can be used to find consequences of assumptions, simulation modeling can be used as an aid to intuition.” -- Robert Axelrod Axelrod R. Advancing the art of simulation in the social sciences. In: Conte R, Hegselmann R, Terna P, editors. Simulating Social Phenomena. New York, NY: Springer; 1997. p. 21-40.. Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000. Simulation Experiments Open a Third Branch of Science “The complexity of our mental models vastly exceeds our ability to understand their implications without simulation." -- John Sterman How? Where? Prevalence of Obese Adults, United States Why? Data Source: NHANES 2020 2010 Who? What?

25. Syndemics Prevention Network An Alternative Philosophical Tradition 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?” We are not talking about theories to explain, but conceptual, methodological, and moral orientations: the frames of reference that shape how we think, how we act, how we learn, and what we value

26. Syndemics Prevention Network All models, including simulations, are wrong: incomplete and imprecise But some are better than others and capture more important aspects of the real world’s dynamic complexity A valuable model is one that can help us understand and anticipate better than we do with the unaided mind How Should We Value Simulation Studies? Artist: Rene Magritte Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531. Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68. “All models are wrong, some are useful.” -- George Box

27. 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 Ecological Thinking Governing Dynamics Causal Mapping Plausible Futures Dynamic Modeling Navigational Freedoms Democratic Public Work

28. Syndemics Prevention Network For Additional Information http://www.cdc.gov/syndemics