Bobby Milstein 7 th Annual Force Health Protection Conference Albuquerque, NM August 10, 2004

1. Force Health Protection Under a Syndemic OrientationFrom Force Health Protection, To Forces for Protecting Health Bobby Milstein 7th Annual Force Health Protection Conference Albuquerque, NMAugust 10, 2004

2. “New recruits” Karen Kasmauski, National Geographic, 1988 Paradox of Protecting Health in an Unhealthy Enterprise “For most people peace is not the highest value. People, groups, and governments will not renounce violence when that is seen to mean becoming powerless and helpless in a conflict in which their basic beliefs and the nature of their society are, or are believed to be, under attack.” -- Gene Sharp Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf.

3. Science, 256, (12 June 1992) pp. 1520-1521

4. Preparing for Inevitable Conflict “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 N J: Princeton University Press, 1988.

5. PREVENTION SCIENCE SYSTEM SCIENCES(improving understanding) SOCIAL NAVIGATION (directing movement) • What conditions protectpeople’s health and safety? • What causes population health problems? • How and when do health systems change? Directing Change • Who does the work to effect change? • How do they act? • What do they value? Charting Progress • Are conditions changing? • In what directions? PUBLIC HEALTH(setting goals) What are health leaderstrying to accomplish? Joining Fields of Inquiry InnovativeHealth Ventures

6. A Glimpse Into 2020 • Falling Below Top 15 • Measles • Malaria • Falls • Anemia • Malnutrition • Rising Into Top 15 • War • HIV • Violence • Self-inflicted injury • Cancer of the trachea, bronchus, and lung Murray CJL, Lopez AD. The global burden of disease: summary. Cambridge, MA: Harvard University Press, 1996.

7. Public Health Goals Are Expanding…and Accumulating “The perfection of means and confusion of goals characterizes our age.” -- Albert Einstein • Prevent disease and injury (~1850 -- present) • Promote health and development (1974 -- present) • Assure the conditions in which people can be healthy (1988 -- present)

8. What does it mean to organize science and society around the goal of assuring healthful conditions?

9. “We are redefining CDC as the nation’s health-protection agency.” -- Julie Gerberding Time 100: the people who shape our world. Time Magazine 2004 April 26.

10. Hygeia and Panacea “In no single thing do men approach the Gods more nearly, than in the giving of safety to mankind.” – Cicero

11. Exploring the Potential of a Syndemic Orientation • A study of innovations in health planning and evaluation • Member network includes • 244 individuals • 175 organizations • 11 countries Centers for Disease Control and Prevention. Spotlight on syndemics. Syndemics Prevention Network, 2001. Available at <http://www.cdc.gov/syndemics>.

12. 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. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Social Science and Medicine 1994;39(7): 931-948. Singer M. A dose of drugs, a touch of violence, a case of AIDS: Conceptualizing the SAVA syndemic. Free Inquiry in Creative Sociology 1996;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.

13. Living Focusing on Relationships “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying • The word syndemicsignals special concern for many kinds of relationships: • mutually reinforcing health problems • health status and living conditions • character and composition of the health response system Health Powerto Act Conditions A syndemic orientation clarifies the dynamic and democratic character of public health work Milstein B. Spotlight on syndemics. Centers for Disease Control and Prevention, 2001. <http://www.cdc.gov/syndemics>

14. Moving Toward a Complementary Science of Relationships • Efforts to Reduce Population Health ProblemsProblem, problem solver, response • Efforts to Organize a System that Protects Population 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.

15. 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." -- Judith Summers Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117.

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

17. 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. Meadows DH, Richardson J, Bruckmann G. Groping in the dark: the first decade of global modelling. New York, NY: Wiley, 1982.

18. 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 produced) 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>.

19. 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.” -- Joèel de Rosnay Rosnay Jd. The macroscope: a book on the systems approach. Principia Cybernetica, 1997. <http://pespmc1.vub.ac.be/MACRBOOK.html

20. The Health System Exhibits Many of Our Toughest Challenges • Dynamic complexityCause and effect are distant in time and space • Social complexityDiverse stakeholders with different agendas and worldviews • Adaptive complexitySolutions from the past may no longer be as effective Adapted from: Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.

21. Lead paint ban 1976 18 Can solder phase-out begins 1978 16 Unleaded gasoline introduced 1979 14 12 Blood Lead Levels (mg/dL) 10 Lead & copper rule 1991 Can solder ends 1992 8 Leaded gas ends 1996 6 4 2.7 2.0 2 0 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 Year Blood Lead Levels in the U.S. Population 1976–1999

22. Adult Per Capita Cigarette Consumption and Major Smoking-and-Health EventsUnited States, 1900-1998 1st Surgeon General’s Report Broadcast Ad Ban Federal Cigarette Tax Doubles End of WW II Nonsmokers Rights Movement Begins 1st Smoking- Cancer Concern Great Depression Source: USDA; 1986 Surgeon General's Report

23. 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 300 200 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.

24. Even the Greatest Gains are Fragile

25. “Solutions” Can Also Create 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.

26. 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 Population

27. 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.

28. 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.

29. 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. http://www.aeinstein.org/. 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.

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

31. Steps in a Syndemic Approach • Identify place or population • Organize with residents/members to: • Identify afflictions and their relationships • Examine living conditions and why they differ • Devise beneficial system-wide policies • Build power to act • Direct the course of social change to assure the conditions for health for all • Expand to other places/populations, as necessary

32. Solving for Pattern "A bad solution is bad because it acts destructively upon the larger patterns in which it is contained...because it is formed in ignorance or disregard of them. A bad solution solves for a single purpose or goal, such as increased production. And it is typical of such solutions that they achieve stupendous increase in production at exorbitant biological and social costs…Good solutions recognize that they are part of a larger whole. They solve more than one problem and don't create new problems. A good solution should not enrich one person by the distress or impoverishment of another." -- Wendell Berry Berry W. Solving for pattern. In: The Gift of Good Land. San Francisco: North Point; 1981. p. 134-45.

33. Solving Problems and Creating Value "In problem solving we seek to make something we do not like go away. In creating, we seek to make what we truly care about exist… We can get so caught up in reacting to problems that it is easy to forget what we actually want. Organizations must do both–resolve day-to-day problems and generate new results. But if your primary role is to fix problems, individually or collectively, rather than create something new and meaningful, it's hard to maintain a sense of purpose, and..it's difficult to harness the energy, passion, commitment, and perseverance needed to thrive in challenging times." -- Peter Senge Senge PM. Creating desired futures in a global society. Reflections 2003;5(1):1-12.

34. Misleading Framing Assumptions • Focus on the events • Everything that happens must have a cause, and that cause must be close in time and space • Instantaneous impacts • Causality runs one-way • Independence • Impacts are linear and constant Richmond B, Peterson S, High Performance Systems Inc. An introduction to systems thinking. Hanover NH: High Performance Systems, 1997.

35. Basic Problem Solving Orientations Event Oriented View Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

36. Decisions Delay Delay “Side Effects” Goals Delay Delay Delay Delay Environment Delay Delay Goals of “Side Delay Delay Others Effects” Delay Actions of Delay Others Basic Problem Solving Orientations Feedback View Sterman J. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

37. 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 responses (syndemic)

38. What happens if we shift from thinking about the variable-as-cause to the system-as-cause? Argyris C. Actionable knowledge: design causality in the service of consequential theory. Journal of Applied Behavioral Science 1996;32(4):390-408. Dent E. The interactional model: an alternative to the direct cause and effect construct for mutually causal organizational phenomena. Foundations of Science in press. Richmond B. The "thinking" in systems thinking: seven essential skills. Waltham, MA: Pegasus Communications, 2000.

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. Infrastructure 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 Conditions Health Protection as a System From: 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.

42. Assuring Healthful Conditions in War and the Preparation for War Adverse Effects on… • People • Environment • Civic infrastructure • Human rights Health Effects • Combatants • Noncombatants Levy BS, Sidel VW. War and public health. Updated ed. Washington DC: American Public Health Association, 2000.

43. Declining Deaths Among Combatants Garfield RM, Neugut AI. The human consequences of war. In: Barry S. Levy VWS, editor. War and public health. Updated ed. Washington DC: American Public Health Association; 2000. p. 27-38.

44. Increasing Deaths Among Noncombatants Garfield RM, Neugut AI. The human consequences of war. In: Barry S. Levy VWS, editor. War and public health. Updated ed. Washington DC: American Public Health Association; 2000. p. 27-38.

45. “New recruits” Karen Kasmauski, National Geographic, 1988 Rethinking the Paradox “For most people peace is not the highest value. People, groups, and governments will not renounce violence when that isseen to mean becoming powerless and helpless in a conflict in which their basic beliefs and the nature of their society are, or are believed to be, under attack.” -- Gene Sharp Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf.

46. Methods of Nonviolent Action “Nonviolent action has nothing to do with passivity, submissiveness, and cowardice; just as in violent conflict, these must first be rejected and overcome.” -- Gene Sharp • Acts of omission (N=61 types) -- Strikes, boycotts, civil disobedience • Acts of commission (N=137 types) -- Blockade, sabotage, counterfeiting • Combinations of both Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf. Sharp G. Correcting common misconceptations about nonviolent action. Albert Einstein Institution, 1973. Accessed May 24, 2004 at <http://65.109.42.80/organizations/org/misconceptions.pdf>.

47. Prospects for Wielding Power through Nonviolent Action “The strength of even dictatorships is dependent on sources of power in the society, which in turn depend on the cooperation of a multitude of institutions and people—cooperation which may or may not continue.” -- Gene Sharp “It is not about making a point, its about taking power.” -- Ackerman & DuVall Sharp G. There are realistic alternatives. Boston Mass: Albert Einstein Institution, 2003. http://65.109.42.80/organizations/org/TARA.pdf. Ackerman P, DuVall J. With weapons of the will: how to topple Saddam Hussein--nonviolently. Sojourners Magazine 2002(September-October).

48. Who Will Be Our Model for Powerful Action in Conflict? Achilles Ashoka

49. Ashoka’s Strategy • Security through powerful nonviolent action • Education • Transportation (roads with shade trees) • Well-digging (clean water) • Hospitals (people and animals) • Religious tolerance

50. Primary Prevention for War? "America was not on a road to survival before Martin Luther King. Atlanta would not look like the thriving metropolis that it is now. Atlanta would probably look more like Beirut if history had gone its normal course, the normal violent American way." -- Andrew Young From: Kearns K. In Remembrance of Martin. PBS Video, 1999.