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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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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
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>.
“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
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
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.)
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
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
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
“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>.
“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>.
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)
“[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>.
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?
The Approach Ought to Be…The Approach Ought to Be…
Ecological
Collaborative
Evidence-based
Ethical
Others?
Ecological
Collaborative
Evidence-based
Ethical
Others?
How would we proceed using a syndemic orientation?
How would we proceed using a syndemic orientation?
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
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
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
What problems have surfaced using conventional approaches?
What problems have surfaced using conventional approaches?
Recurring Evaluation ChallengesRecurring Evaluation Challenges
Linking comprehensive interventions to categorical disease outcomesLinking comprehensive interventions to categorical disease outcomes
Balancing ValuesBalancing Values
“Scientific”Evidence of Effects
ComprehensiveInterventions
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.
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
Logical Links?Logical Links?
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
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
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
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.
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
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
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
“[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.
How would our health promotion venture operate under a syndemic orientation?
How would our health promotion venture operate under a syndemic orientation?
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!
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
Core Public Health Functions Under a Syndemic OrientationCore Public Health Functions Under a Syndemic Orientation
System Dynamics
SocialNavigation
POLICYDEVELOPMENT
ASSESSMENT
ASSURANCE
NetworkAnalysis
CategoricalOrientationSyndemic
Orientation
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
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
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
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
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?
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?
Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/
Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/
Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/
Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/
Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/
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
Formalize Navigational ImageryFormalize Navigational Imagery
See NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.aspSee NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.asp
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
Selected Navigational StatisticsSelected Navigational Statistics
a°
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/
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/
a°
rh
a = 52°
r = 0.76n = 5
p=.05*
a°
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
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>.
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
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.
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
For Additional Informationhttp://www.cdc.gov/syndemics