1 / 96

Syndemics, System Science, and the Prospect of Navigating Health Futures

Syndemics, System Science, and the Prospect of Navigating Health Futures. Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics. Coordinating Center for Health Promotion

kalila
Download Presentation

Syndemics, System Science, and the Prospect of Navigating Health Futures

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Syndemics, System Science, and the Prospect of Navigating Health Futures Bobby Milstein Syndemics Prevention NetworkCenters for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics Coordinating Center for Health Promotion Centers for Disease Control and Prevention October 29, 2007

  2. CoCHP Coordinates Many of Our Highest Priorities Need to Connect Groups Focused on… • Diseases/Disabilitiesarthritis, birth defects, cancer, diabetes, epilepsy, heart disease and stroke, obesity, oral health, mental health • Riskstobacco, nutrition, physical activity, alcohol, sexual behavior, ACEs, racism, genetics • Lifestagesinfants, children, adolescents, adults, older adults, reproductive age/pregnancy • Placesschools, communities, healthcare settings, global • Sciencessurveillance, prevention research, evaluation, social epidemiology, communications, economics, GIS, genomics, syndemics, well-being, quality of life • National initiativesREACH, STEPS, WISEWOMAN, MS Delta, VERB

  3. Imperatives for Protecting Health Typical Current State“Static view of problems that are studied in isolation” Proposed Future State“Dynamic systems and syndemic approaches” “Currently, application of complex systems theories or syndemic science to health protection challenges is in its infancy.” -- Julie Gerberding Gerberding JL. Protecting health: the new research imperative. Journal of the American Medical Association 2005;294(11):1403-1406.

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

  5. Model VenturesHealthy Hawaii Initiative “The Healthy Hawaii Initiative is the only long-term, statewide program to implement a social ecological approach to reduce obesity, increase physical activity, and improve nutrition.” Percentage Change in Health Indicators Hawaii and US, 1998-2003 Overweight/Obese Adults Leisure TimeActivity 5+ Fruit/Vegper Day Partnership for Prevention. Innovation in prevention awards announced. Washington, DC; October 26, 2006. <http://www.prevent.org/content/view/120/144/>.

  6. A Navigational View of Public Health Work Where we want to go? How do we prepare to get there? Where you do want to live? Where do you want your children to live? 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>. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007.

  7. A Navigational View of Public Health Work "How do you know," I asked, "that in twenty years those things that you consider special are still going to be here?" At first they all raised their hands but when they really digested the question every single one of them put their hands down. In the end, there was not a single hand up. No one could answer that question. It was the most uncomfortable moment of silence that I can remember…That was the defining moment for me. I recognized that I have to participate in answering that question otherwise I am not taking responsibility for the place I love and the people I love.” -- Nainoa Thompson Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.

  8. A Navigational View of Public Health Work "How do you know," I asked, "that in twenty years those things that you consider special are still going to be here?" At first they all raised their hands but when they really digested the question every single one of them put their hands down. In the end, there was not a single hand up. No one could answer that question. It was the most uncomfortable moment of silence that I can remember…That was the defining moment for me. I recognized that I have to participate in answering that question otherwise I am not taking responsibility for the place I love and the people I love.” -- Nainoa Thompson Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at <http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html>.

  9. Innovation, Pragmatism, and the Promise of “What If…” Thinking Positivism • Begins with a theory about the world • Learning through observation and falsification • Asks, “Is this theory true?” 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?” "Grant an idea or belief to be true…what concrete difference will its being true make in anyone's actual life? -- William James These are conceptual, methodological, and moral orientations, which shape how we think, how we act, how we learn, and what we value Shook J. The pragmatism cybrary. 2006. Available at <http://www.pragmatism.org/>. 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.

  10. Seeing Syndemics Health “Health Policy” Power to Act “Social Policy” Living Conditions “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying • Studying innovations in public health work, with emphasis on transformations in concepts, methods, and moral orientations • The word syndemic signals special concern for many kinds of relationships: • mutually reinforcing health problems • health status and living conditions • synergy/fragmentation in the health protection system (e.g., by issues, sectors, organizations, professionals and other citizens) “Citizen-ship” A syndemic orientation clarifies the dynamic and democratic character of public health work • 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 Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>

  11. Exploring the Dynamic and Democratic Characterof Public Health Work UNDERSTANDING CHANGESystems Science GOVERNING MOVEMENT Social Navigation • 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? SETTING DIRECTIONPublic Health What are health leaderstrying to accomplish? PUBLIC HEALTH WORK InnovativeHealth Ventures

  12. Changing (and Accumulating) Views of Population HealthWhat Accounts for Poor Population Health? 1840 1880 1950 1960 1980 2000 • 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., hierarchical modeling) • Dynamic feedback among afflictions, living conditions, and public strength (e.g., syndemic orientation) Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world [Doctoral Dissertation]. Cincinnati, OH: Union Institute & University; 2006. Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.

  13. 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 Epi·demic 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 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.

  14. 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 fragile, dynamic state requiring continual effort to maintain and one that is imperiled when social and physical forces operate in harmful ways Syn·demic Events System Co-occurring Confounding Connecting* Synergism Syndemic * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping

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

  16. Seeing Beyond the Probable “Most organizations plan around what is most likely. In so doing they reinforce what is, even though they want something very different.” -- Clement Bezold • PossibleWhat may happen? • PlausibleWhat could happen? • ProbableWhat will likely happen? • PreferableWhat do we want to have happen? Bezold C, Hancock T. An overview of the health futures field. Geneva: WHO Health Futures Consultation; 1983 July 19-23.

  17. Re-Directing the Course of ChangeQuestions of Social Navigation Historical Markov Forecasting Model Data Prevalence of Diagnosed Diabetes, United States 40 Where? 30 Million people 20 What? How? • Markov Model Constants • Incidence rates (%/yr) • Death rates (%/yr) • Diagnosed fractions • (Based on year 2000 data, per demographic segment) 10 Trend is not destiny Who? Why? 0 1980 1990 2000 2010 2020 2030 2040 2050 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.

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

  19. There Have Been Remarkable Successes in Redirecting the Course of Change 684,000 fewer deaths in 1998 alone Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 700 Rate if trend continued 600 500 Peak Rate 400 Age-adjusted Death Rate per 100,000 Population 300 • Overall Decline is Linked to… • Reduced smoking • Changes in diet • Better diagnosis and treatment • More heath services utilization 200 Actual Rate 100 50 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 Year Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003. Centers for Disease Control and Prevention. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke -- United States, 1900-1999. MMWR 1999;48(30):649-656. Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm>

  20. Fewer Deaths Mean More People Living with Illness and its Associated Burden and Costs Consumer Price Indices for Healthcare and the General Economy United States, 1960-2004 (1960=1) Consumer price index (CPI-U) relative to 1960 16 12 Healthcare 8 4 Total economy 0 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004

  21. Healthcare Cost is Also the Leading Driver of Personal Bankruptcy Total Personal Bankruptcy Filings, United States, 1994-2006 61% of the filers surveyed failed to seek needed medical treatments American Bankruptcy Institute. Bankruptcy filing statistics: non-business filings. Alexandria, VA: American Bankruptcy Institute; October, 2007. <http://www.abiworld.org/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=48428>. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Affairs 2005:hlthaff.w5.63. Available at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63v1 Fox M. Half of Bankruptcy Due to Medical Bills -- U.S. Study: Reuters; February 2, 2005.

  22. Worsening Trend in Summary Measures of Population Health Average Number of Adult Unhealthy Days per Month, United States, 1993-2006 17% increase Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2007. Accessed October 23, 2007 at <http://apps.nccd.cdc.gov/HRQOL/index.asp>. Zack MM, Moriarty DG, Stroup DF, Ford ES, Mokdad AH. Worsening trends in adult health-related quality of life and self-rated health–United States, 1993-2001. Public Health Reports 2004;119(5):493-505.

  23. Entrenched Inequities

  24. Entrenched Inequities Life Expectancy at Birth in the Eight Americas (1982-2001) Murray CJ, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: investigating mortality disparities across races, counties, and race-counties in the United States. PLoS Med 2006;3(9). Available at <http://medicine.plosjournals.org/archive/1549-1676/3/9/pdf/10.1371_journal.pmed.0030260-L.pdf>

  25. 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 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.

  26. Looking Through the Macroscope “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.” -- Joèl de Rosnay Rosnay J. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html

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

  28. Boundary Critique Creating a new theory is not like destroying an old barn and erecting a skyscraper in its place. It is rather like climbing a mountain, gaining new and wider views, discovering unexpected connections between our starting point and its rich environment. -- Albert Einstein Ulrich W. Boundary critique. In: Daellenbach HG, Flood RL, editors. The Informed Student Guide to Management Science. London: Thomson; 2002. p. 41-42. <http://www.geocities.com/csh_home/downloads/ulrich_2002a.pdf>. 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

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

  30. Implications for Policy Planning and Evaluation Insights from the Overview Effect • Maintain a particular analytic distance • Not too close to the details, but not too far as be insensitive to internal pressures • Potential to anticipate temporal patterns (e.g., better before worse) • Structure determines behavior • Potential to avoid scapegoating or lionizing Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991. Richmond B. Systems thinking: critical thinking skills for the 1990s and beyond. System Dynamics Review 1993;9(2):113-134. Available at <http://www.clexchange.org/ftp/documents/whyk12sd/Y_1993-05STCriticalThinking.pdf>. White F. The overview effect: space exploration and human evolution. 2nd ed. Reston VA: American Institute of Aeronautics and Astronautics, 1998.

  31. Broad Street, One Year Later John Snow Heroic Success or Cautionary Tale? “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." Centers for Disease Control and Prevention. 150th anniversary of John Snow and the pump handle. MMWR 2004;53(34):783. Available at <http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5334a1.htm> Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117. Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007.

  32. John Snow Heroic Success or Cautionary Tale? Galea S. Macrosocial determination of population health: the example of urbanization. NCEH/ATSDR Director's Science Seminar Series; Atlanta, GA: Centers for Disease Control and Prevention; February 7, 2007.

  33. What Do These Observations Having in Common? • Low tar and low nicotine cigarettesLead to greater carcinogen intake • Fad dietsProduce diet failure and weight gain • Road building to ease congestionAttracts development, increases traffic, delays, pollution, and urban sprawl • Antibiotic & pesticide useStimulate resistant strains • Air-conditioning useRaises neighborhood heat • Forest fire suppressionBuilds deadwood fueling larger, hotter, more dangerous fires • War on drugsRaises price and attracts supply • Suppressing dissentInspires radicalization and extremism Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

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

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

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

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

  38. Seeking High-Leverage Policies “Give me a firm place to stand and I will move the earth.” -- Archimedes Wall painting in the Stanzino delle Matematiche in the Galleria degli Uffizi (Florence, Italy). Painted by Giulio Parigi in the years 1599-1600. Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999. Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.

  39. Expanding Public Health Science Syndemic Orientation Governing Dynamics CausalMapping Dynamic Modeling Problems Among People inPlaces Over Time Plausible Futures Boundary Critique DemocraticPublic Work Navigational Freedoms “Public health imagination involves using science to expand the boundaries of what is possible.” -- Michael Resnick EpidemicOrientation

  40. Working Harder to AchieveHealth Protection…Health Equity Gerberding JL. CDC: protecting people's health. Director's Update; Atlanta, GA; July, 2007. Gerberding JL. Health protectionomics: a new science of people, policy, and politics. Public Health Grand Rounds; Washington, DC: George Washington University School of Public Health and Health Services; September 19, 2007. Available at <http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2349> Centers for Disease Control and Prevention. Health system transformation: Office of Strategy and Innovation; September 28, 2007. <http://intradev.cdc.gov/od/osi/policy/healthSystems_overview.htm>. Time 100: the people who shape our world. Time Magazine 2004 April 26.

  41. The Dynamics of Upstream and Downstream: Why is So Hard for the Health System to Work Upstream? Upstream Prevention and Protection ----------------------------------- Total  3% Downstream Care and Management -------------------------------- Total  97% Centers for Medicaid and Medicare Services. National health expenditures. Centers for Medicaid and Medicare Services, 2006. <http://www.cms.hhs.gov/NationalHealthExpendData/>. Levi J, Trust for America's Health. Shortchanging America's health 2006: a state-by-state look at how federal public health dollars are spent. Washington, DC: Trust for America's Health, 2006. Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Jackson DJ, Valdesseri R, CDC Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 2004. <http://intranet.cdc.gov/od/futures/wrkgroup/stage_i/hswg.htm>

  42. Health System Dynamics 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 “One major task that CDC is intending to address is balancing this portfolio of our health system so that there is much greater emphasis placed on health protection, on making sure that we invest the same kind of intense resources into keeping people healthier or helping them return to a state of health and low vulnerability as we do to disease care and end of life care." -- Julie Gerberding Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Gerberding JL. FY 2008 CDC Congressional Budget Hearing. Testimony before the Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, United States House of Representatives; Washington, DC; March 9, 2007. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458. 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.

  43. Prerequisite Conditions for Health • Peace • Shelter • Education • Food • Income • Stable eco-system • Sustainable resources • Social justice and equity Endorsed at five world conferences on health promotion (1986-2000) 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. Available at <http://www.who.int/hpr/archive/docs/ottawa.html>.

  44. Seeing Conditions as Freedoms • Adverse living conditions are circumstances that inhibit people's freedom to be safe and healthy and develop their full potential • They include, at a minimum, any deviation from prerequisite conditions for life and human dignity (e.g., physical extremes, violence, deprivation, disconnection) • Phenomena like hunger, homelessness, joblessness, illiteracy, war, environmental decay, and various forms of injustice, including racism, are all examples of adverse living conditions Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Milstein B, Homer J. System dynamics modeling work in progress: the dynamics of upstream and downstream. Syndemics Prevention Network, Centers for Disease Control and Prevention. Atlanta, GA. Available at http://www.cdc.gov/syndemics

  45. Balancing Two Major Areas of Emphasis Public Work Medical and Public Health Policy Healthy Public 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 Afflicted with Vulnerable Healthier without Complications People People Developing Becoming Becoming Complications complications vulnerable afflicted DEMOCRATIC SELF-GOVERNANCE MANAGEMENT OF DISEASES AND RISKS Dying from complications Adverse Living Conditions • World of Transforming… • Deprivation • Dependency • Violence • Disconnection • Environmental decay • Stress • Insecurity • Etc… • By Strengthening… • Leaders and institutions • Foresight and precaution • The meaning of work • Mutual accountability • Plurality • Democracy • Freedom • Etc… • World of Providing… • Education • Screening • Disease management • Pharmaceuticals • Clinical services • Physical and financial access • Etc… Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007.

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

  47. Refining the Hypothesis Incorporating Public vs. Professional Concern

  48. Health System DynamicsIncorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.

  49. Health System DynamicsIncorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.

  50. Health System DynamicsIncorporating Public vs. Professional Concern Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Centers for Disease Control and Prevention; Draft, 2007. Milstein B, Homer J. Health system dynamics: mapping the drivers of population health, vulnerability, and affliction. Atlanta, GA: Syndemics Prevention Network; June 27 (work in progress), 2006.

More Related