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Navigating Health Futures in a Dynamic and Democratic World

Navigating Health Futures in a Dynamic and Democratic World. Bobby Milstein Syndemics Prevention Network Centers for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics. University of Auckland School of Population Health New Zealand Ministry of Health

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Navigating Health Futures in a Dynamic and Democratic World

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  1. Navigating Health Futures in a Dynamic and Democratic World Bobby Milstein Syndemics Prevention NetworkCenters for Disease Control and Prevention bmilstein@cdc.gov http://www.cdc.gov/syndemics University of Auckland School of Population Health New Zealand Ministry of Health Auckland: September 12-14, 2007 Wellington: September 19-21, 2007

  2. Topics for Today • Principles of a Syndemic Orientation • A Navigational View of Public Health Work • Dealing with Dynamic Complexity • Policy resistance • Boundary critique • Crafting high-leverage interventions • Causal mapping and simulation modeling • Building power • Illustrations • North Karelia Project • CDC Diabesity Modeling • Industrial Areas Foundation • Questions and Discussion Throughout

  3. Chronic Conditions Here (and Everywhere) Are… • Common • Diverse • Interconnected • Increasing • Costly • Debilitating • Deadly • Inequitably distributed • Largely preventable Defy quick fixes and require a sound system-wide strategy to protect health as well as other values

  4. How to Meet the Challenge? “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. 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.

  6. 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.

  7. 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 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

  8. 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 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

  9. 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>

  10. Working DefinitionSyndemic Orientation 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.

  11. 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., ?) • Single disease, single cause (e.g., ?) • Single disease, multiple causes (e.g., ?) • Single cause, multiple diseases (e.g., ?) • Multiple causes, multiple diseases (but no feedback dynamics) (e.g., ?) • Dynamic feedback among afflictions, living conditions, and public strength (e.g., ?) 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.

  12. Exposes the Dynamic and Democratic Dimensions of 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

  13. 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.

  14. 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.

  15. Reconnecting with a Voyaging Tradition “Nainoa Thompson, who studied under Mau Pialug, became the first Hawaiian navigator in over 500 years to guide a canoe over this traditional route without instruments.” -- Polynesian Voyaging Society

  16. 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. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.

  17. 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>.

  18. 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>.

  19. Foundations of Directed Change Knowledge Power Morality Facts Self Effects Consciousness Conscience Scire, to know Science

  20. Chronic Conditions are Classic Examples of Dynamically Complex Problems • Differences between short- and long-term consequences of an action • Time delays (e.g., developmental period, time to detect, time to respond) • Accumulations (e.g., prevalences, resources, attitudes) • Behavioral feedback (e.g., reactions by various actors) • Nonlinear causal relationships (e.g., threshold effects, saturation effects) • Differences or inconsistencies in goals/values among stakeholders Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458.

  21. 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

  22. 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.

  23. 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.

  24. 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.

  25. “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 +

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

  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 of service delivery, but not too far as to miss the internal pressures of vulnerability, capacity, and health status • Potential to explain temporal patterns (e.g., better before worse) • Structure determines behavior • Potential to avoid scapegoating 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. 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>.

  32. Navigational VenturesFinland’s North Karelia Project Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995. National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Available at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.

  33. Focusing the Intervention Policy Policy B: Focus on Risk Conditions for All Policy A: Focus on High Risk Individuals Puska P. The North Karelia Project: 20 year results and experiences. Helsinki: National Public Health Institute, 1995

  34. Broad Intervention PolicyNorth Karelia Project Individual Effort Disease Burden Public Work Adapted from Puska P. North Karelia International Visitors’ Programme, 2003. Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at <http://www.publicwork.org/1_2_philosophy.html>.

  35. Directing ChangeNorth Karelia Project • Selected Action Strategies • Medical services, if necessary • Newspaper coverage: articles, editorials, letters • TV time: highly rated 30-45 minute shows (no PSAs) • Housewives’ organization: cooking and dietary choices • Opinion leaders: role models, support groups, public action • Tax shifting: tobacco, butter, milk • Economic Renewal • Decline of dairy • Rise of berry • Rise of vegetable oil and rapeseed oil • Rise of healthier breads, cheeses, sausages, etc Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995.

  36. Transforming All Dimensionsof the System Efforts to Fight Afflictions Health Efforts to Build Power Power to Act Living Conditions Efforts to Improve Adverse Living Conditions

  37. Efforts to Fight Afflictions (design/deliver) Screening Education Risk reduction counseling Medical/pharmaceutical treatment Disease self-management Directing ChangeNorth Karelia Project

  38. Efforts to Improve Adverse Living Conditions (develop/promote) Tobacco legislation Food-labeling requirements Margarines and oils Low-fat milk Low-fat, low-salt, high-fiber bread Vegetable-containing sausage (with mushrooms) Berry farming and consumption Community competitions, morale, and social norms State welfare system (at the national, regional, sub-regional, and local levels) Directing ChangeNorth Karelia Project

  39. Health Professionals Physicians Health Educators Psychologists Epidemiologists Sociologists Hospital administrators Pharmaceutical manufacturers Nurses Rehabilitation therapists Other Citizens Bakers Farmers Grocers Food scientists, manufacturers Restaurant owners Housewives Entertainers Entrepreneurs Journalists, media professionals Teachers School administrators Elected representatives Building PowerNorth Karelia Project

  40. Charting ProgressNorth Karelia Project Vartiainen E, Puska P, Pekkanen J, Toumilehto J, Jousilahti P. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. British Medical Journal 1994;309(6946):23-27.

  41. Charting ProgressNorth Karelia Project -49% -68% -73% -44% -71% Puska P. The North Karelia Project : 20 year results and experiences. Helsinki: National Public Health Institute, 1995. National Public Health Institute. North Karelia international visitor's programme. National Public Health Institute, 2003. Accessed May 30, 2004 at <http://www.ktl.fi/eteo/cindi/northkarelia.html>.

  42. Framing the Challenge of Chronic Illness PERSONPeople living with affliction Health States & Rates TIME People vulnerable to affliction PLACE Areas with a recurring problem of affliction

  43. 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.

  44. 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. Doctoral dissertation. Cincinnati, OH: Union Institute and University. November, 2006.

  45. 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. Unpublished dissertation. Cincinnati, OH: Union Institute and University; April 13, 2006 (draft). 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

  46. Choice and Non-Choice “Choices are always made from among alternatives presented by the social environment, or by circumstances that were themselves not chosen…When we recognize the elements of non-choice in choice, we can escape the contradiction between social causation and individual responsibility and understand the interactiveness of the two.” Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93.

  47. 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

  48. Evaluating Dynamic, Democratic Policies 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) How can we learn about the consequences of alternative policies in a system of this kind?

  49. System Dynamics Was Developed to Address Problems Marked By Dynamic Complexity Good at Capturing • Differences between short- and long-term consequences of an action • Time delays (e.g., incubation period, time to detect, time to respond) • Accumulations (e.g., prevalences, resources, attitudes) • Behavioral feedback (reactions by various actors) • Nonlinear causal relationships (e.g., threshold effects, saturation effects) • Differences or inconsistencies in goals/values among stakeholders Origins • Jay Forrester, MIT, Industrial Dynamics, 1961 (“One of the seminal books of the last 20 years.”-- NY Times) • Public policy applications starting late 1960s • Population health applications starting mid-1970s Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000. Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public Health 2006;96(3):452-458.

  50. Learning In and About Dynamic Systems Strategy, Structure, Mental Decision Rules Models Real World • Unknown structure • Dynamic complexity • Time delays • Impossible experiments Virtual World • Known structure • Controlled experiments • Enhanced learning • Implementation • Game playing • Inconsistency • Short term • Selected • Missing • Delayed • Biased • Ambiguous Information Decisions Feedback • Inability to infer dynamics from mental models • Misperceptions • Unscientific • Biases • Defensiveness Sterman JD. Learning in and about complex systems. System Dynamics Review 1994;10(2-3):291-330. Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

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