An Introduction to Syndemics: Implications for Health Promotion

1. An Introduction to Syndemics: Implications for Health Promotion Bobby MilsteinSyndemics Prevention NetworkCenters for Disease Control and Preventionbmilstein@cdc.govhttp://www.cdc.gov/syndemics Introduction to Health Promotion (PH 7016) Georgia State University April 19, 2006 Atlanta, GA

2. “Let me assure you, we will survive any crisis that involves funding, political support, popularity, or cyclic trends, but we can't survive the internal crisis, if we become provincial, focus totally on the short term, or if we lose our philosophy of social justice.” -- William Foege Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.

3. What forces move us to become externally focused, provincial, short-term oriented, and neglectful of social justice? What approaches to public health work may help us to recognize and overcome these pitfalls?

4. What single word best conveys the message of this report? Institute of Medicine. The future of public health. Washington, D.C.: National Academy Press, 1988

5. 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.

6. New Word for a Familiar Phenomenon “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 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.

7. What was Singer doing? What are the implications for public health work? What principles and methodologies support this perspective (scientifically, politically, morally)? What effects do these ways of thinking and acting have on individuals and in the world at large?

8. What Does it Mean to Approach Public Health Work from a Syndemic Orientation? • Ongoing study of innovations in public health work • Member network includes • 419 individuals • 280 organizations • 19 countries Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. <http://www.cdc.gov/syndemics>.

9. Starting Premises • Public health work has changed significantly since its formalization in the 19th century, and even today it is poised for further transformation • It matters how we think about the trends, dilemmas, and innovations that we experience, and it matters whether our thinking and actions match • 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, and what we value

10. Plan for Today • Explore the meaning and implications of a syndemic orientation • Discuss how conceptual, methodological, and moral considerations shape the (changing) character of public health work • Illustrate how system dynamics maps and simulation models can support innovative thinking and action

11. The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“ Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work Epi·demic

12. Public Health Began as Public Work “Public death was first recognized as a matter of civilized concern in the nineteenth century, when some public health workers decided that untimely death was a question between men and society, not between men and God….Since then, and for that reason, millions of lives have been saved….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 Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972.

13. 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 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 Events Systems Syn·demic Co-occurring Confounding Connecting* Synergism Syndemic * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

14. 1840 1880 1950 1960 1980 2000 Changing (and Accumulating) Ideas in Causal TheoryWhat accounts for poor population health? • God’s will • Humors, miasma, ether • Poor living conditions, immorality (sanitation) • Single disease, single cause (germ theory) • Single disease, multiple causes (heart disease) • Single cause, multiple diseases (tobacco) • Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology) • Dynamic feedback among afflictions, living conditions, and public strength (syndemic) Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

15. Seeing Syndemics “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying The word syndemic signals a special concern for relationships • Mutually reinforcing character of health problems • Connections between health status and living conditions • Synergy/fragmentation within the health system (e.g., by issues, sectors, organizations, professionals and other citizens)

16. Health Public Strength Living Conditions Placing Health in a Wider Set of Relationships A syndemic orientation is one of a few approaches that includes within it our power to respond

17. A Philosophy of Means “About the ideal goal of human effort there exists in our civilization and, for nearly thirty centuries, there has existed a very general agreement….Not so with regard to the roads which lead to that goal. Here unanimity and certainty give place to utter confusion, to the clash of contradictory opinions, dogmatically held and acted upon with the violence of fanaticism.” -- Aldous Huxley Huxley A. Ends and means: an inquiry into the nature of ideals and into methods employed for their realization. New York, NY: Harper, 1937.

18. A Philosophy of Means “Social and political theory have neglected the central question of means, and, therefore, the problem of inevitable conflict.” -- Joan Bondurant Bondurant JV. Conquest of violence: the Gandhian philosophy of conflict. New rev. ed. Princeton NJ: Princeton University Press, 1988.

19. Toward a Complementary Science of Relationships “True innovation occurs when things are put together for the first time that had been separate.” – Arthur Koestler • Efforts to Reduce Population Health ProblemsProblem, problem solver, response • Efforts to Organize a System that Assures the Conditions for HealthDynamic interaction among multiple problems, problem solvers, and responses Bammer G. Integration and implementation sciences: building a new specialisation. Cambridge, MA: The Hauser Center for Nonprofit Organizations, Harvard University 2003.

20. There is Great Power in Focusing on One Problem at a Time "Certain forms of knowledge and control require a narrowing of vision. The great advantage of such tunnel vision is that it brings into sharp focus certain limited aspects of an otherwise far more complex and unwieldy reality. This very simplification, in turn, makes the phenomenon at the center of the field of vision more legible and hence more susceptible to careful measurement and calculation….making possible a high degree of schematic knowledge, control, and manipulation." -- James Scott Scott JC. Seeing like a state: how certain schemes to improve the human condition have failed. New Haven ; London: Yale University Press, 1999.

21. Even the Greatest Gains are Fragile

22. Broad Street, One Year Later “No improvements at all had been made...open cesspools are still to be seen...we have all the materials for a fresh epidemic...the water-butts were in deep cellars, close to the undrained cesspool...The overcrowding appears to increase." Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.

23. SpecializationA Proven Problem Solving Approach • Identify disease • Determine causes • Develop and test interventions • Implement programs and policies • Repeat steps 1-4, as necessary!

24. Issue Organizations A B C D E D B E A C Side Effects of Specialization • Confusion, inefficiency, organizational disarray • Competition for shared 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 Neighborhood

25. Dangers of Getting Too Specific • Conventional problem solving proliferates problems • Opens a self-reinforcing niche for professional problem solvers • Obscures patterns that transcend any specific problem (e.g., nonviolence is entirely neglected) Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002.

26. Examples of Nonviolent Action • Dismantling dictatorships • Blocking coups d’état • Defending against foreign invasions and occupations • Providing alternatives to violence in extreme ethnic conflicts • Challenging unjust social and economic systems • Developing, preserving and extending democratic practices, human rights, civil liberties, and freedom of religion • Resisting genocide “A phenomenon that cuts across ethnic, cultural, religious, geographic, socioeconomic and other demographic lines.” -- Albert Einstein Institution Albert Einstein Institution. Applications of nonvilolent action. Albert Einstein Institution, 2001. Powers RS, Vogele WB, Kruegler C, McCarthy RM. Protest, power, and change: an encyclopedia of nonviolent action from ACT-UP to women's suffrage. New York: Garland Pub., 1997.

27. SYSTEMS THINKING & MODELING (understanding change) SOCIAL NAVIGATION (governing movement) • 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)? Directing Change • Who does the work? • By what means? • According to whose values? Charting Progress • How are conditions changing? • In which directions? PUBLIC HEALTH(setting direction) What are health leaderstrying to accomplish? Questioning the Character of Public Health Work PUBLIC HEALTH WORK InnovativeHealth Ventures

28. Syndemic OrientationWorking Definition 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 21st century systems science and political sensibilities, but the underlying concepts are not new. Still, the implications of adhering to this orientation remain largely unexplored. Milstein B. Syndemic. In: Mathison S, editor. Encyclopedia of Evaluation. Thousand Oaks, CA: Sage Publications; 2004.

29. Core Public Health Functions Under a Syndemic Orientation ASSESSMENT SocialNavigation NetworkAnalysis CategoricalOrientation SyndemicOrientation System Dynamics POLICYDEVELOPMENT ASSURANCE

30. “Solutions” CanCreate New Problems 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.

31. Many Systems Exhibit Policy Resistance “The tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.” -- Meadows, Richardson, Bruckman “At least six times since the Depression, the United States has tried and failed to enact a national health insurance program.” -- Lee & Paxman Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35. Pear R. Health spending rises to record 15% of economy. The New York Times 2004 January 9. Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.

32. Flaws in Previous Attempts at Health Reform in America • Piecemeal approaches • Comprehensive strategies that are opposed by special interests • Assumption that healthcare dynamics are separate from other areas of public concern • Conventional analytic methods make it difficult to • Observe the health system as a large, dynamic enterprise • Craft high-leverage strategies that can overcome policy resistance • Been thinking of health and healthcare as nouns (i.e., commodities to be distributed), not as verbs (i.e., public work to be crafted) Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999. Kari NN, Boyte HC, Jennings B. Health as a civic question. American Civic Forum, 1994. Available at <http://www.cpn.org/topics/health/healthquestion.html>.

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

34. Boundary Critique 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

35. Boundary Critique 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

36. “You Can Argue with Einstein” “For certain purposes, public judgment should carry more weight than expert opinion – and not simply because the majority may have more political power than the individual expert but because the public’s claim to know is actually stronger than the experts’...the judgment of the general public can, under some conditions, be equal or superior in quality to the judgment of experts and elites who possess far more information, education, and ability to articulate their views.” -- Daniel Yankelovich Yankelovich D. Coming to public judgment: making democracy work in a complex world. 1st ed Syracuse, NY: Syracuse University Press, 1991. p. 220.

37. 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 These assumptions overlook non-local forces of change, such as feedback and delay Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.

38. What causes the behaviors we observe?

39. System-as-Cause

40. “When we attribute behavior to people rather than system structure the focus of management becomes scapegoating and blame rather than the design of organizations in which ordinary people can achieve extraordinary results.” Beyond Scapegoating -- John Sterman “The tendency to blame other people instead of the system is so strong that psychologists call it the fundamental attribution error.” Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.

41. A Very Particular Distance “The feedback perspective stems from viewing the system from ‘a very particular distance', not so close as to be concerned with the action of a single individual, but not so far away as to be ignorant of the internal pressures in the system.” -- George Richardson Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

42. Looking Through the Macroscope “A symbolic instrument made of a number of methods and techniques borrowed from very different disciplines…The macroscope filters details and amplifies that which links things together. It is not used to make things larger or smaller but to observe what is at once too great, too slow, and too complex for our eyes.” -- Joèel de Rosnay Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html

43. What processes or phenomena might we need a macroscope to see?

44. Events Time Series Models Describe trends • Increasing: • Depth of causal theory • Degrees of uncertainty • Robustness for longer-term projection • Value for developing policy insights Multivariate Stat Models Identify historical trend drivers and correlates Patterns Dynamic Models Anticipate future trends, and find policies that maximize chances of a desirable path Structure Tools for Policy Analysis

45. Public Work Society's Health Response Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier Safer Afflicted Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted Dying from complications Adverse Living Conditions Health System Dynamics 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.

46. Citizen Involvement in Public Life Public Strength - Vulnerable and Afflicted People Fraction of Adversity, Social Division Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) Understanding Health as Public Work Public Work - Society's Health Response Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier - Safer Afflicted Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted Dying from complications Adverse Living Conditions

47. Healthy Public Policy & Public Work Medical and Public Health Policy Public Work Society's Health Response Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier Safer Afflicted DEMOCRATIC SELF-GOVERNANCE MANAGEMENT OFRISKS AND DISEASES Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted • World of Transforming… • Deprivation • Dependency • Violence • Discrimination • Environmental decay • Stress • Insecurity • By Strengthening… • Leaders and institutions • Foresight and precaution • The meaning of work • Mutual accountability • Plurality • Democracy • Freedom • World of Providing… • Health Education • Screening • Disease management • Pharmaceuticals • Clinical services • Physical and financial access Dying from complications Adverse Living Conditions Balancing Two Areas of Emphasis

48. Public Work Citizen Involvement - in Public Life Public Society's Health Strength Response - Tertiary General Targeted Primary Secondary Prevention Protection Protection Prevention Prevention Demand for response Becoming safer and healthier - Safer Afflicted Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted Dying from complications Adverse Living Conditions Vulnerable and Afflicted People Fraction of Adversity, Social Division Vulnerability and Affliction Borne by Disadvantaged Sub-Groups (Inequity) Testing Dynamic Hypotheses -- How can we learn about the consequences of actions in a system of this kind?-- Could the behavior of this system be analyzed using conventional epidemoiological methods (e.g., logistic or multi-level regression)?

49. Learning In and About Dynamic Systems “The complexity of our models vastly exceeds our ability to understand their implications without simulation." -- John Sterman Benefits of Simulation/Game-based Learning • Formal means of evaluating options • Experimental control of conditions • Compressed time • Complete, undistorted results • Actions can be stopped or reversed • Visceral engagement and learning • Tests for extreme conditions • Early warning of unintended effects • Opportunity to assemble stronger support Complexity Hinders • Generation of evidence (by eroding the conditions for experimentation) • Learning from evidence (by demanding new heuristics for interpretation) • Acting upon evidence (by including the behaviors of other powerful actors) Sterman JD. Learning from evidence in a complex world. AJPH 2006;96(3):505-514. Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000.

50. …in an Era of Epidemic Obesity Transforming the Future of Diabetes… "Every new insight into Type 2 diabetes...makes clear that it can be avoided--and that the earlier you intervene the better. The real question is whether we as a society are up to the challenge...Comprehensive prevention programs aren't cheap, but the cost of doing nothing is far greater..." Gorman C. Why so many of us are getting diabetes: never have doctors known so much about how to prevent or control this disease, yet the epidemic keeps on raging. how you can protect yourself. Time 2003 December 8. Accessed at http://www.time.com/time/covers/1101031208/story.html.