1. Seeing Syndemics Thoughts on Improving Public Health in Communities Challenged by Multiple Afflictions Bobby Milstein 16th National Conference on Chronic Disease Prevention and Control Atlanta, GA (February 28, 2002)

2. How might public health practice be different under a syndemic orientation?

3. SYNDEMIC: two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population. Working Definition

4. “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi saying Seeing Syndemics

5. A Syndemic Network General Community Conditions Ties Afflictions

6. Syndemic Orientation Syndemic Orientation Balancing Values “Scientific” Evidence of Effects Comprehensive Health Improvement

7. 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. Working Definition

8. Broad Goals in Public Health Eliminating health disparities Reducing overall burden of disease Avoiding activity limitation Maintaining emotional balance Promoting life satisfaction Eliminating health disparities Reducing overall burden of disease Avoiding activity limitation Maintaining emotional balance Promoting life satisfaction

9. Quick Recap A Syndemic Orientation Places multiple afflictions in context Begins with a concern for defining the community Identifies links among the entire set of afflictions Provides a precise framework for understanding the forces that perpetuate health disparities Joins the science of epidemiology with the action agenda of community leaders A Syndemic Orientation Places multiple afflictions in context Begins with a concern for defining the community Identifies links among the entire set of afflictions Provides a precise framework for understanding the forces that perpetuate health disparities Joins the science of epidemiology with the action agenda of community leaders

10. Types of Affliction Ties Incidence Recovery Incidence Recovery Common causes Same biological agent Same risk behaviors Similar environments Managed by same or similar organizations Common causes Same biological agent Same risk behaviors Similar environments Managed by same or similar organizations Direct Indirect

11. Preliminary Dynamic Model http://broadcast.forio.com/sims/syndemic/

12. Basic Dynamic Relations ConnectionInfluenceDirection Proximity DataFeedback DataNavigational Data What links to what? What influences what? Where am I now? Where can I go? What can I do here? How do I get back to where I was?

13. Core Public Health Functions Under a Syndemic Orientation System Dynamics Social Navigation POLICY DEVELOPMENT ASSESSMENT ASSURANCE Network Analysis Syndemic Orientation

14. A Few Implications Complements the conventional categorical approach Alters the notion of confounding by questioning the overall pattern of associations Avoids the need for comparison or control groups through simulated experiments in a given community Adheres to a navigational perspective that compares current position to the chosen destination, as opposed to an earlier starting point Fosters essential partnerships with the health sector, and between health and other sectors Complements the conventional categorical approach Alters the notion of confounding by questioning the overall pattern of associations Avoids the need for comparison or control groups through simulated experiments in a given community Adheres to a navigational perspective that compares current position to the chosen destination, as opposed to an earlier starting point Fosters essential partnerships with the health sector, and between health and other sectors

15. The Work to be Done Understanding syndemics Using a syndemic orientation Diffusing a syndemic orientation Understanding syndemics Using a syndemic orientation Diffusing a syndemic orientation

16. Syndemic Network Members in the US International Africa Australia International Africa Australia http://www.cdc.gov/syndemic

17. Syndemics Prevention Network http://www.cdc.gov/syndemics