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Seeing Syndemics

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

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  1. 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

  2. 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>.

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

  4. Definition:Syndemic Two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population.

  5. 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.)

  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. 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.

  7. 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

  8. Healthy People Healthy World Through Prevention Your Mission Assure the conditions in which people can be healthy • Improve health • Enhance living conditions • Strengthen capacity

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

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

  11. Officially endorsed at all five world conferences on health promotion (1986-2000) Prerequisite Conditions • Income • Stable eco-system • Sustainable resources • Social justice and equity • Peace • Shelter • Education • Food 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>.

  12. Definition:Capacity for Action “[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. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at <http://www.who.int/hpr/docs/glossary.html>.

  13. Starting 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 How will you proceed?

  14. The Approach Ought to Be… • Ecological • Collaborative • Evidence-based • Ethical • Others?

  15. How would we proceed using a syndemic orientation?

  16. Caveats • 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

  17. Definition:Syndemic Orientation 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.

  18. SECONDARY &TERTIARY PRIMARY & SECONDARY INTERGENERATIONAL Biological Change Behavioral Change Social Change Focus on Affliction Focus on Risk Focus on Conditions Healing Services Disease Prevention Health Promotion Focus on Capacity for Action Capacity Building or Empowerment Infrastructural Change Spectrum of Prevention Time Horizon for Observing Effects on Population Health Status* SHORTmonths-years LONGdecades-centuries INTERMEDIATEyears-decades * 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

  19. What problems have surfaced using conventional approaches?

  20. Recurring Evaluation Challenges • Linking comprehensive interventions to categorical disease outcomes

  21. “Scientific”Evidence of Effects ComprehensiveInterventions Balancing Values

  22. Mismatch Between “Gold Standard” Intervention and Evaluation* Source: Schorr LB. Common purpose: strengthening families and neighborhoods to rebuild America. New York, NY: Doubleday, Anchor Books, 1997.

  23. Recurring Evaluation Challenges • Linking comprehensive interventions to categorical disease outcomes • Leaps of faith leading to overall health improvement

  24. Logical Links?

  25. Imply that prerequisite conditions exist and that most, if not all, disease prevention programs are effective simultaneously Goals Have a Nested Structure Disease Prevention • Prevent disease and injury • Health Promotion • Prolong length • Improve quality • Eliminate disparity • Enhance satisfaction • Public Health • Assure the conditions for health for all

  26. Recurring Evaluation Challenges • Linking comprehensive interventions to categorical disease outcomes • Leaps of faith leading to overall health improvement • Side effects of specialization

  27. Institutions A B C D E D B E A C Side Effects of Specialization • Noise • Inefficiency • Competition • Coercive power dynamics • Neglected feedback (+ and -) • Confounded evaluations • Limited mandate to address living conditions • Disappointing track record Community

  28. 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.

  29. Forces of change suggest one of these paths: Outlook for Future Effectiveness Afflictions Under Control* 1850 2100 2000 Year * That is for certain subgroups; except in the case of smallpox, no afflictions have been controlled equitably

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

  31. 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) 1840 1880 1950 1960 1980 2000

  32. The Feedback Thought “[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 From: http://www.systemdynamics.org/ See also: Richardson GP. Feedback thought in social science and systems theory. Philadelphia: University of Pennsylvania Press, 1991.

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

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

  35. Steps in a Syndemic Approach • 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

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

  37. Focus on Relational Questions and Relational Data

  38. Capacity to Act Living Conditions Ties Afflictions Assessment “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying

  39. Policy Development “The future is not to be predicted, but created.” -- Arthur C. Clarke • 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

  40. 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 Development

  41. Preliminary Dynamic Model Under What Conditions Do Syndemics Emerge? How Can they be Controlled? Affliction prevalence Community capacity General community conditions

  42. Key Rectangle: Stock/state variable Blue arrow: same-direction link Green arrow: opposite-direction link Circled “B”: balancing causal loop Circled “R”: reinforcing causal loop Preliminary Dynamic Model Under What Conditions Do Syndemics Emerge? How Can they be Controlled?

  43. Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/

  44. Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/

  45. Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/

  46. Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/

  47. Web-based Simulation Gamehttp://broadcast.forio.com/sims/syndemic/

  48. Assurance “The path resounds to our footfall, but do we have it in ourselves to change direction?” -- Peter Ustinov • 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

  49. Formalize Navigational Imagery See NACCHO website: http://nacchoweb.naccho.org/MAPP_Home.asp

  50. Basic 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) • Time • Energy • Resistance • Alignment • Navigational aids • Charting

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