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Seeing Syndemics Thoughts on Improving Public Health in Communities Challenged by Multiple Afflictions Bobby Milstein CDC Work in Progress Seminar Emerging Investigations and Analytic Methods July 18, 2002

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Seeing Syndemics. Thoughts on Improving Public Health in Communities Challenged by Multiple Afflictions. Bobby Milstein CDC Work in Progress Seminar Emerging Investigations and Analytic Methods July 18, 2002. - PowerPoint PPT Presentation

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Page 1: Seeing Syndemics

Seeing SyndemicsSeeing Syndemics

Thoughts on Improving Public Health in Communities Challenged by Multiple Afflictions

Thoughts on Improving Public Health in Communities Challenged by Multiple Afflictions

Bobby MilsteinCDC Work in Progress Seminar

Emerging Investigations and Analytic MethodsJuly 18, 2002

Bobby MilsteinCDC Work in Progress Seminar

Emerging Investigations and Analytic MethodsJuly 18, 2002

Page 2: Seeing Syndemics

Robert Wood Johnson Foundation. A portrait of the chronically ill in America, 2001. Princeton, NJ: Robert Wood Johnson Foundation and the Foundation for Accountability; 2002. <http://www.rwjf.org/publications/publicationsPdfs/report_chronic_illness.pdf>.

Page 3: Seeing Syndemics

“Populations at risk for one chronic

disease are often at risk for multiple

chronic diseases, and the risk factors

underlying these diseases are often

similar…Public health research is

increasingly looking for and evaluating

the effectiveness of methods for

integrating programs and services to

meet the interconnected needs of

populations.”

“Populations at risk for one chronic

disease are often at risk for multiple

chronic diseases, and the risk factors

underlying these diseases are often

similar…Public health research is

increasingly looking for and evaluating

the effectiveness of methods for

integrating programs and services to

meet the interconnected needs of

populations.”

-- National Center for Chronic Disease Prevention and Health Promotion-- National Center for Chronic Disease Prevention and Health Promotion

See: http://www.cdc.gov/nccdphp/agenda/index.htmSee: http://www.cdc.gov/nccdphp/agenda/index.htm

Page 4: Seeing Syndemics

Two or more afflictions, interacting

synergistically, contributing to excess

burden of disease in a population.

Two or more afflictions, interacting

synergistically, contributing to excess

burden of disease in a population.

Definition:Syndemic

Definition:Syndemic

Page 5: Seeing Syndemics

Syndemics Involve…Syndemics Involve…

The spread and persistence of mutually

reinforcing health problems typically found in

communities with unfavorable living conditions

(e.g., economic hardship, deteriorated

infrastructure, social disruption, institutionalized

racism, inadequate health care, etc.)

The spread and persistence of mutually

reinforcing health problems typically found in

communities with unfavorable living conditions

(e.g., economic hardship, deteriorated

infrastructure, social disruption, institutionalized

racism, inadequate health care, etc.)

Page 6: Seeing Syndemics

New Word for a Familiar PhenomenonNew Word for a Familiar Phenomenon

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. 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.

“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.”

“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-- Merrill Singer

Page 7: Seeing Syndemics

Picture a Community Where…Picture a Community Where…

Conditions are not supportive of healthy living

People are either afflicted by or at risk for mutually reinforcing health problems

Community leaders are making an effort to fight the afflictions and improve living conditions, but their capacity to do so is limited

More could be done with backing from government and philanthropies

Conditions are not supportive of healthy living

People are either afflicted by or at risk for mutually reinforcing health problems

Community leaders are making an effort to fight the afflictions and improve living conditions, but their capacity to do so is limited

More could be done with backing from government and philanthropies

Page 8: Seeing Syndemics

Your MissionYour Mission

Improve health

Enhance living conditions

Strengthen capacity

Improve health

Enhance living conditions

Strengthen capacity

Assure the conditions in which people can be healthy

Assure the conditions in which people can be healthy

Healthy PeopleHealthy People

Healthy WorldHealthy World

Through PreventionThrough Prevention

Page 9: Seeing Syndemics

“A state of complete physical, social and mental well-being, and not merely the

absence of disease or infirmity.”

“A state of complete physical, social and mental well-being, and not merely the

absence of disease or infirmity.”

-- World Health Organization-- World Health Organization

Definition:Health

Definition:Health

World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.

Page 10: Seeing Syndemics

“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.”

“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.”

-- World Health Organization-- World Health Organization

Definition:Living Conditions

Definition:Living Conditions

World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.

Page 11: Seeing Syndemics

Prerequisite Conditions Prerequisite Conditions

Peace

Shelter

Education

Food

Peace

Shelter

Education

Food

Income

Stable eco-system

Sustainable resources

Social justice and equity

Income

Stable eco-system

Sustainable resources

Social justice and equity

World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

Officially endorsed at all five world conferences on health promotion (1986-2000)

Officially endorsed at all five world conferences on health promotion (1986-2000)

Page 12: Seeing Syndemics

“[The ability of] individuals and organizations to apply their skills and

resources in collective efforts to address health priorities and meet their

respective health needs.”

“[The ability of] individuals and organizations to apply their skills and

resources in collective efforts to address health priorities and meet their

respective health needs.”

-- World Health Organization-- World Health Organization

Definition:Capacity for Action

Definition:Capacity for Action

World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.

Page 13: Seeing Syndemics

Starting AssumptionsStarting Assumptions

Effective responses to complex community health problems require system-wide interventions

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 engrained in financial structures, problem solving frameworks, statistical models, and criteria for professional prestige

Effective responses to complex community health problems require system-wide interventions

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 engrained in financial structures, problem solving frameworks, statistical models, and criteria for professional prestige

How will you proceed?How will you proceed?

Page 14: Seeing Syndemics

The Approach Ought to Be…The Approach Ought to Be…

Ecological

Collaborative

Evidence-based

Ethical

Others?

Ecological

Collaborative

Evidence-based

Ethical

Others?

Page 15: Seeing Syndemics

How would we proceed using a syndemic orientation?

How would we proceed using a syndemic orientation?

Page 16: Seeing Syndemics

CaveatsCaveats

Work in progress

Case studies have yet to begin

Another in a class of ecological models

Not “new”, but a novel way of combining longstanding public health traditions with theories and methods from other applied sciences

Open to evolve in many directions

Work in progress

Case studies have yet to begin

Another in a class of ecological models

Not “new”, but a novel way of combining longstanding public health traditions with theories and methods from other applied sciences

Open to evolve in many directions

Page 17: Seeing Syndemics

A public health perspective that assesses

connections between health-related problems,

considers those connections when developing

prevention policies, and aligns with other

avenues of social change to assure the

conditions in which people can be healthy.

A public health perspective that assesses

connections between health-related problems,

considers those connections when developing

prevention policies, and aligns with other

avenues of social change to assure the

conditions in which people can be healthy.

Definition:Syndemic Orientation

Definition:Syndemic Orientation

Page 18: Seeing Syndemics

Spectrum of PreventionSpectrum of Prevention

SHORTmonths-years

INTERMEDIATEyears-decades

LONGdecades-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

BehavioralChange

Focus on RiskDisease Prevention

INTERGENERATIONAL

Social Change

Focus on ConditionsHealth Promotion

Focus on Capacity for ActionCapacity Building or Empowerment

Infrastructural Change

Page 19: Seeing Syndemics

What problems have surfaced using conventional approaches?

What problems have surfaced using conventional approaches?

Page 20: Seeing Syndemics

Recurring Evaluation ChallengesRecurring Evaluation Challenges

Linking comprehensive interventions to categorical disease outcomesLinking comprehensive interventions to categorical disease outcomes

Page 21: Seeing Syndemics

Balancing ValuesBalancing Values

“Scientific”Evidence of Effects

ComprehensiveInterventions

Page 22: Seeing Syndemics

Mismatch Between “Gold Standard” Intervention and Evaluation*

Mismatch Between “Gold Standard” Intervention and Evaluation*

Attributes of Interventions Associated with “Effectiveness”

Attributes of Interventions Associated with “Evaluability”

significant front-line flexibility standardized; discretion minimized

evolving, in response to experience and changing conditions

constant over time

intervention/program design reflecting local strengths, needs, preferences

intervention/program centrally designed, uniform across sites

intake/recruitment into program under local control within broad parameters

intake/recruitment into program centrally designed to permit random assignment

multi-factor single factor

interactive components components clearly separable

emphasize continuity of respectful relationships, other “hard-to-measure” inputs

readily measured inputs

implementers “believe in” the intervention value-free implementation

Source: Schorr LB. Common purpose: strengthening families and neighborhoods to rebuild America.New York, NY: Doubleday, Anchor Books, 1997.

Page 23: Seeing Syndemics

Recurring Evaluation ChallengesRecurring Evaluation Challenges

Linking comprehensive interventions to categorical disease outcomes

Leaps of faith leading to overall health improvement

Linking comprehensive interventions to categorical disease outcomes

Leaps of faith leading to overall health improvement

Page 24: Seeing Syndemics

Logical Links?Logical Links?

Page 25: Seeing Syndemics

Goals Have a Nested StructureGoals Have a Nested StructureDisease Prevention

Prevent disease and injury

Disease Prevention

Prevent disease and injury

Imply that prerequisite conditions exist and that most, if not all, disease

prevention programs are effective simultaneously

Imply that prerequisite conditions exist and that most, if not all, disease

prevention programs are effective simultaneously

Health Promotion

• Prolong length

• Improve quality

• Eliminate disparity

• Enhance satisfaction

Health Promotion

• Prolong length

• Improve quality

• Eliminate disparity

• Enhance satisfaction

Public Health

• Assure the conditions for health for all

Public Health

• Assure the conditions for health for all

Page 26: Seeing Syndemics

Recurring Evaluation ChallengesRecurring Evaluation Challenges

Linking comprehensive interventions to categorical disease outcomes

Leaps of faith leading to overall health improvement

Side effects of specialization

Linking comprehensive interventions to categorical disease outcomes

Leaps of faith leading to overall health improvement

Side effects of specialization

Page 27: Seeing Syndemics

Side Effects of SpecializationSide Effects of Specialization

Noise

Inefficiency

Competition

Coercive power dynamics

Neglected feedback (+ and -)

Confounded evaluations

Limited mandate to address living conditions

Disappointing track record

Noise

Inefficiency

Competition

Coercive power dynamics

Neglected feedback (+ and -)

Confounded evaluations

Limited mandate to address living conditions

Disappointing track record

A

C

BD

E

A B C D EInstitutions

Community

Page 28: Seeing Syndemics

Diseases of DisarrayDiseases 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.

Page 29: Seeing Syndemics

Outlook for Future EffectivenessOutlook for Future Effectiveness

Afflictions Under Control*

Afflictions Under Control*

YearYear

1850 2000 2100

Forces of change suggest one of these paths:

* That is for certain subgroups; except in the case of smallpox, no afflictions have been controlled equitably

Page 30: Seeing Syndemics

What problem solving strategy is appropriate for assuring the conditions in which people can be healthy?

What problem solving strategy is appropriate for assuring the conditions in which people can be healthy?

Sword in the StoneSword in the Stone

Page 31: Seeing Syndemics

Brief History of Public Health Problem SolvingWhat accounts for poor community health?

Brief History of Public Health Problem SolvingWhat 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 (CVD)

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 (CVD)

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

Page 32: Seeing Syndemics

“[When X and Y affect each other] one cannot study the link between X and Y and,

independently, the link between Y and X and predict how the system will behave. Only the study of the whole

system as a feedback system will lead to correct results."

“[When X and Y affect each other] one cannot study the link between X and Y and,

independently, the link between Y and X and predict how the system will behave. Only the study of the whole

system as a feedback system will lead to correct results."

-- System Dynamics Society-- System Dynamics Society

The Feedback ThoughtThe Feedback Thought

From: http://www.systemdynamics.org/

See also: Richardson GP. Feedback thought in social science and systems theory. Philadelphia: University of Pennsylvania Press, 1991.

Page 33: Seeing Syndemics

How would our health promotion venture operate under a syndemic orientation?

How would our health promotion venture operate under a syndemic orientation?

Page 34: Seeing Syndemics

Conventional Problem Solving Approach

Conventional Problem Solving Approach

Identify disease

Determine causes

Develop and test interventions

Implement programs and policies

Identify disease

Determine causes

Develop and test interventions

Implement programs and policies

Repeat steps 1-4, as necessary!Repeat steps 1-4, as necessary!

Page 35: Seeing Syndemics

Identify community

Cooperate with community members in:

Identifying afflictions and their relationships

Examining living conditions and why they differ

Devising beneficial system-wide policies

Strengthening capacity to act

Advocating for directed social change to assure the conditions for health for all

Expand to other communities, as necessary

Identify community

Cooperate with community members in:

Identifying afflictions and their relationships

Examining living conditions and why they differ

Devising beneficial system-wide policies

Strengthening capacity to act

Advocating for directed social change to assure the conditions for health for all

Expand to other communities, as necessary

Steps in a Syndemic ApproachSteps in a Syndemic Approach

Page 36: Seeing Syndemics

Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation

System Dynamics

SocialNavigation

POLICYDEVELOPMENT

ASSESSMENT

ASSURANCE

NetworkAnalysis

CategoricalOrientationSyndemic

Orientation

Page 37: Seeing Syndemics

Focus on Relational Questions and Relational Data

Focus on Relational Questions and Relational Data

AssessmentNetwork Analysis

Policy DevelopmentSystem Dynamics

AssuranceSocial Navigation

What links to what?

What influences what?

What policies have the greatest leverage?

What backlash could occur?

Where are we going?

Where are we now?

How close are we?

Where can we go from here?

Proximity Data Feedback Data Navigational Data

Page 38: Seeing Syndemics

AssessmentAssessment

Capacity to Act

Living Conditions

Ties

Afflictions

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

“You think you understand two because you understand one and one. But you must also understand ‘and’.”

-- Sufi Saying

Page 39: Seeing Syndemics

Policy DevelopmentPolicy Development

Maximize all three parts of the mission: health, living conditions, and capacity

Explicit model building

Simulated experiments

What if…

What futures are possible?

Real world action and observation

Maximize all three parts of the mission: health, living conditions, and capacity

Explicit model building

Simulated experiments

What if…

What futures are possible?

Real world action and observation

“The future is not to be predicted, but created.”

-- Arthur C. Clarke

“The future is not to be predicted, but created.”

-- Arthur C. Clarke

Page 40: Seeing Syndemics

Time Series ModelsDescribe 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 Models

Anticipate future trends, and find policies that maximize chances

of a desirable path

Tools for Policy DevelopmentTools for Policy Development

Page 41: Seeing Syndemics

Afflictionprevalence

Generalcommunityconditions

Communitycapacity

Preliminary Dynamic Model Under What Conditions Do Syndemics Emerge?

How Can they be Controlled?

Preliminary Dynamic Model Under What Conditions Do Syndemics Emerge?

How Can they be Controlled?

Page 42: Seeing Syndemics

KeyRectangle: Stock/state variableBlue arrow: same-direction linkGreen arrow: opposite-direction linkCircled “B”: balancing causal loopCircled “R”: reinforcing causal loop

Afflictionprevalence

Generalcommunityconditions

Out-migration ofnon-afflicted

Afflictioncontagion andcross-impacts

Investments incommunity

Affliction-related death

Communityefforts to fight

affliction

Community effortsto improve general

conditions

Temporaryassistance to

build capacity

R

R

R

R

R

B

B

B

Communitycapacity

Temporaryassistance tofight affliction

Temporaryassistance to

improve generalconditions

Availablecommunity

capacity

R

Disruption due toexternally controlled

assistance

R

Preliminary Dynamic Model Under What Conditions Do Syndemics Emerge?

How Can they be Controlled?

Preliminary Dynamic Model Under What Conditions Do Syndemics Emerge?

How Can they be Controlled?

Page 48: Seeing Syndemics

AssuranceAssurance

Implement policies by aligning health with other avenues of social change

Advocacy driven by community leaders in partnership with health professionals

Navigational perspective, guided by community vision and values

Forward orientation

Adapts to changing conditions

Implement policies by aligning health with other avenues of social change

Advocacy driven by community leaders in partnership with health professionals

Navigational perspective, guided by community vision and values

Forward orientation

Adapts to changing conditions

“The path resounds to our footfall, but do we have it in ourselves to change direction?”

-- Peter Ustinov

“The path resounds to our footfall, but do we have it in ourselves to change direction?”

-- Peter Ustinov

Page 49: Seeing Syndemics

Formalize Navigational ImageryFormalize Navigational Imagery

See NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.aspSee NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.asp

Page 50: Seeing Syndemics

Basic Concepts in Navigational ScienceBasic Concepts in

Navigational Science

Position (current state)

Destination (goals, values)

Direction (chosen course)

Distance (difference from goal)

Drift (deflection from course)

Set (distance to get back on course)

Conditions (physical, historical or evolutionary context)

Position (current state)

Destination (goals, values)

Direction (chosen course)

Distance (difference from goal)

Drift (deflection from course)

Set (distance to get back on course)

Conditions (physical, historical or evolutionary context)

Time

Energy

Resistance

Alignment

Navigational aids

Charting

Time

Energy

Resistance

Alignment

Navigational aids

Charting

Page 51: Seeing Syndemics

Selected Navigational StatisticsSelected Navigational Statistics

rh

a = 52°

r = 0.76n = 5

p=.05*

Adapted from: Baker RR. Human navigation and the sixth sense. New York, NY: Simon and Schuster. 1981.

Oriana website: http://www.kovcomp.co.uk/oriana/

Page 52: Seeing Syndemics

Selected Navigational StatisticsSelected Navigational Statistics

Adapted from: Baker RR. Human navigation and the sixth sense. New York, NY: Simon and Schuster. 1981.

Oriana website: http://www.kovcomp.co.uk/oriana/

rh

a = 52°

r = 0.76n = 5

p=.05*

r

h

a = 128°

r = 0.76n = 5

p=.05*

Group A Group B

p=.001*

Group comparisons are possible, but not requiredGroup comparisons are possible, but not required

Page 53: Seeing Syndemics

Planning the VoyagePlanning the Voyage

"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…”

-- Nainoa Thompson-- Nainoa Thompson

Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.

Page 54: Seeing Syndemics

Charting the Course for Social Change

Charting the Course for Social Change

A Safe, Nurturing Social Environment

(14 indicators)

A Safe, Nurturing Social Environment

(14 indicators)

A Thriving, Diverse, Sustainable Economy

(15 indicators)

A Thriving, Diverse, Sustainable Economy

(15 indicators)

A Healthy Natural Environment

(10 indicators)

A Healthy Natural Environment

(10 indicators)

Civic Vitality(5 indicators)Civic Vitality(5 indicators)

Educated Citizens(8 indicators)

Educated Citizens(8 indicators)

Aloha Spirit(2 indicators)Aloha Spirit

(2 indicators)

Sta

te L

aw (

SC

R 1

2)

Hawai'i Community Services Council. Ke Ala Hoku critical indicators report. Honolulu: Hawai'i Community Services Council, 1999.

See: http://www.hcsc-hawaii.org/kah/index.htm

Page 55: Seeing Syndemics

ImplicationsImplications

Builds upon established theories and methods

Complements single-issue prevention strategies

Offers simulation modeling as an alternative to experimenting with comparison or control groups

Adheres to a navigational perspective that strengthens leadership and sharpens science

Fosters essential partnerships (between public and professionals; within public health; across sectors)

Advances a specific course of social change, one focused on unifying health, development, justice, and self-determination.

Builds upon established theories and methods

Complements single-issue prevention strategies

Offers simulation modeling as an alternative to experimenting with comparison or control groups

Adheres to a navigational perspective that strengthens leadership and sharpens science

Fosters essential partnerships (between public and professionals; within public health; across sectors)

Advances a specific course of social change, one focused on unifying health, development, justice, and self-determination.

Page 56: Seeing Syndemics

Syndemic Network Members in the USSyndemic Network Members in the US

International

• Argentina

• Australia

• Canada

• Grenada

International

• Argentina

• Australia

• Canada

• Grenada

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

Page 57: Seeing Syndemics

For Additional Informationhttp://www.cdc.gov/syndemics