1. Toward A Syndemic View of Urban Health Challenges Bobby Milstein Minnesota Health Departments December 18, 2003 Bobby Milstein Minnesota Health Departments December 18, 2003

2. The 2007 Urban Crossover Emmi PC. Coupled human–biologic systems in urban areas: towards an analytical framework using dynamic simulation. 21st International Conference of the System Dynamics Society; New York; 2003. United Nations. World urbanization prospects: the 2001 revision. New York: United Nations, 2002. “Historically humans have disproportionately favored a rural and agriculturally based settlement pattern. By the middle of the 20th century, thirty percent of our species lived in urban areas. Mankind is about to cross a cultural threshold when in 2007 we become a predominately urban species.” -- Philip Emmi

3. Tamman M. Charlantingham: welcome to the big city. Atlanta Journal-Constitution 2001 April 15.

4. 9.80 10.52 11.33 13.12 Source: NHTSA 2.51 New York 3.76 San Francisco 6.55 Portland 9.80 Houston 10.52 Phoenix 11.33 Dallas 13.12 Atlanta 5.36 Philadelphia Automobile Fatality Rates by City, 1998 (excluding pedestrian fatalities; deaths/100,000/year)

5. 2.33 New York 4.55 San Francisco 2.58 Portland 3.41 Houston 4.09 Phoenix 4.28 Dallas 6.44 Atlanta 1.88 Philadelphia Pedestrian Fatality Rates by City, 1998 (deaths/100,000/year) Source: NHTSA

6. Health Effects of Sprawl Frumkin H. Urban sprawl and public health. Public Health Reports 2002;117(3):201-17. Physical inactivity Motor vehicle crashes Pedestrian injuries/fatalities Water quality and quantity Air pollution Heat extremes Social capital erosion Mental health problems (Asthma, crime, racism, noise, soil erosion, fossil fuel depletion, others…) Physical inactivity Motor vehicle crashes Pedestrian injuries/fatalities Water quality and quantity Air pollution Heat extremes Social capital erosion Mental health problems (Asthma, crime, racism, noise, soil erosion, fossil fuel depletion, others…)

7. Immense Challenges Ahead King LJ. Safeguarding human and animal health: the changing face of veterinary medicine in 2002. National Press Club; Canberra, Australia: Veterinary Science Foundation, University of Sydney; 2002. United Nations. Department of Economic and Social Development.. Population Division. World urbanization prospects: the 2001 revision. New York: United Nations, 2002. “By 2015 there will be approximately [21] mega cities that will each approach populations of 10 million inhabitants. This trend will exacerbate and expand two new health problems: built environmental conditions and syndemics." -- Lonnie King

8. Ideas About Interaction Confounding Connecting* Synergism Syndemic * Includes several forms of connection or inter-connection such as synergy, intertwining, intersecting, and overlapping Events Systems “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying “You think you understand two because you understand one and one. But you must also understand ‘and’.” -- Sufi Saying Co-occurring

9. "The central urban areas and their suburbs only a few dozen miles away constitute, from a public health viewpoint, a single, strongly interlinked urban-suburban ecosystem rather than the almost random, fragmented, economically and racially segregated array their separate governmental and budgetary systems imply." -- Rodrick & Deborah Wallace Urban-Suburban Ecosystem Wallace R, Wallace D. Inner-city disease and the public health of the suburbs - socio-geographic dispersion of point source infection. Environment and Planning A 1993;25(12):1707-1723.

10. Seeking Syn-Solutions “If the health consequences of sprawl represent a ‘syndemic’–a combination of synergistic epidemics that contributes to the population burden of disease–then solutions may also operate synergistically, ameliorating several health problems.” -- Howard Frumkin Frumkin H. Urban sprawl and public health. Public Health Reports 2002;117(3):201-17.

11. Background on the Syndemics Project Planned as a three-year study of innovations in health planning and evaluation (now in year two) The word syndemic signals special concern for relationships mutually reinforcing character of health problems connections between health status and living conditions synergy/fragmentation within the health system (by issues; sectors; organizations; professionals and citizens) Planned as a three-year study of innovations in health planning and evaluation (now in year two) The word syndemic signals special concern for relationships mutually reinforcing character of health problems connections between health status and living conditions synergy/fragmentation within the health system (by issues; sectors; organizations; professionals and citizens)

12. Placing Health in a Wider Set of Relationships Health Living Conditions Capacity to Act

13. Innovations in Public Health Work Steps in Public Health Problem SolvingTrends and Emerging Priorities Define the problem Eliminate health disparities Avoid activity limitation Promote life satisfaction Increase healthy days Determine the cause Social determinants of health Income inequality Eroding social capital Unhealthy built environment Adverse childhood experiences Develop and test interventions Comprehensive community initiatives Ecological perspectives Inter-sector collaboration Health impact assessments Implement programs and policies Policy interventions Community and systems change Adaptation to local context And scores more….

14. Public health work is becoming more… Inter-connected ( ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability Questioning (evaluative, reflexive, practical) Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends Public health work is becoming more… Inter-connected ( ecological, multi-causal, dynamic, systems-oriented) Concerned more with leverage than control Public (broad-based, partner-oriented, citizen-led, inter-sector, democratic) Concerned with many interests and mutual-accountability Questioning (evaluative, reflexive, practical) Concerned with creating and protecting values like health, security, satisfaction, justice, wealth, and freedom in both means and ends Innovations Point to the Emergence of a Syndemic Orientation Many other orientations rely on disconnected, singular, and unthinking approaches to means and ends (e.g., security by means of war)

15. A Complementary Science of Relationships Efforts to Reduce Population Health Problems Problem, problem solver, response Efforts to Organize a Health System that Protects the Public’s Health Dynamic interaction among multiple problems, problem solvers, and responses Efforts to Reduce Population Health Problems Problem, problem solver, response Efforts to Organize a Health System that Protects the Public’s Health Dynamic interaction among multiple problems, problem solvers, and responses

16. The Transforming Field of Health Action PREVENTION SCIENCE Innovative Health Ventures SYSTEM SCIENCES (improving understanding) What causes population health problems? How is society’s health system organized? Why—and when—does the health system change (or resist change)? Where is the leverage? PUBLIC HEALTH (setting goals) What are leaders in the health system trying to accomplish? SOCIAL NAVIGATION (directing movement) Directing Change Charting Progress Who does the work to effect change? By what means? How are conditions changing? In what directions?

17. Elliot G. Twentieth century book of the dead. New York,: C. Scribner, 1972. “Public death was first recognized as a matter of civilized concern in the nineteenth century, when some public health workers decided that untimely death was a question between men and society, not between men and God. Infant mortality and endemic disease became matters of social responsibility. Since then, and for that reason, millions of lives have been saved….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. Public Health Began as Public Work -- Gil Elliot

18. The term epidemic, first used in 1603, signifies a kind of relationship wherein something is put upon the people Epidemiology appeared 270 years later, in the title of J.P. Parkin's book "Epidemiology, or the Remoter Causes of Epidemic Diseases“ Ever since then, the conditions that cause health problems have increasingly become matters of public concern and public work

19. Changing (and Accumulating) Ideas in Causal Theory What 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 (heart disease) Single cause, multiple diseases (tobacco) Multiple causes, multiple diseases (but no feedback dynamics) (social epidemiology) Dynamic feedback among afflictions, living conditions, and response capacity (syndemic) 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 response capacity (syndemic) 1880 1950 1960 1980 2000 1840 A syndemic orientation is one of a few approaches that includes within it our power to respond

20. 60 0 50 0 40 0 20 0 10 0 50 195019601970198019901995 Rate if trend continued Peak Rate Actual Rate Age-adjusted Death Rate per 100,000 Population 1955196519751985 30 0 70 0 Year Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998 Scott JC. Seeing like a state: how certain schemes to improve the human condition have failed. New Haven ; London: Yale University Press, 1999. "Certain forms of knowledge and control require a narrowing of vision. The great advantage of such tunnel vision is that it brings into sharp focus certain limited aspects of an otherwise far more complex and unwieldy reality. This very simplification, in turn, makes the phenomenon at the center of the field of vision more legible and hence more susceptible to careful measurement and calculation." Benefits of Specialization -- John Scott

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

22. But “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.

23. Side Effects of Specialization Confusion Inefficiency Competition Coercive power dynamics Neglected feedback (+ and -) Confounded evaluations Limited mandate to address living conditions and capacity Disappointing track record, especially with regard to inequalities A C B D E ABCD E Institutions Community

24. Dangers of Remaining Too Specific Krug EG, World Health Organization. World report on violence and health. Geneva: World Health Organization, 2002. Conventional problem solving proliferates problems Opens a self-reinforcing niche for professional problem solvers Obscures patterns that transcend any specific problem Conventional problem solving proliferates problems Opens a self-reinforcing niche for professional problem solvers Obscures patterns that transcend any specific problem

25. Diseases of Disarray Hardening of the categories Tension headache between treatment and prevention Hypocommitment to training Cultural incompetence Political phobia Input obsession 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. 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.

26. Source: Centers for Disease Control and Prevention. Health-related quality of life: prevalence data. National Center for Chronic Disease Prevention and Health Promotion, 2003. Accessed March 21 at. The picture looks different if we think about people’s overall state of health or affliction 14% increase

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

28. Is there some way to get a larger, more dynamic overview of the whole health system without loosing sight of unique disease processes involved?

29. Public Work (organizing, governance, citizenship, mutual accountability) Professional Work (customers, products, services) more inter-organizationally complex, slower rate of improvement organizationally complex, faster rate of improvement FOR SELF INTERESTFOR OTHERS IN NEED Safer, Healthier Population Becoming Vulnerable Becoming no longer vulnerable Vulnerable Population Becoming Afflicted without Complications Developing Complications Targeted protection Primary prevention Secondary prevention Afflicted with Complications Dying from Complications Tertiary prevention Society's Health Response General protection Adverse Living Conditions 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. Basic Dynamics in the Health System

30. “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 Definition: Living Conditions World Health Organization. Health promotion glossary. World Health Organization, 1998. Accessed July 15 at.

31. Dependence on Living Conditions Corning PA. Presidential speech: the systems sciences in the year 3000. International Society of the Systems Sciences, 2000. Accessed April 23, 2002 at. "Each of us has an array of basic needs that must, by and large, be satisfied continuously. We cannot, for instance, do for very long without fresh water, or waste elimination, or sleep. Accordingly, each of us–individually and collectively–requires a synergistic ‘package' of resources and suitable environmental conditions. A society that can reliably provide this package will thrive and possibly grow larger. But if even one of these needs is not satisfied–if any part of the package is deficient–the entire enterprise is likely to be threatened"

32. Seeing Conditions as Freedoms Adverse living conditions are circumstances that inhibit people's freedom to live 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. Adverse living conditions are circumstances that inhibit people's freedom to live 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.

33. Prerequisite Conditions for Health 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. Endorsed at all five world conferences on health promotion (1986-2000) Peace Shelter Education Food Peace Shelter Education Food Income Stable eco-system Sustainable resources Social justice and equity Income Stable eco-system Sustainable resources Social justice and equity

34. Human Development Freedoms Health Education Standard of living Political participation Social engagement Physical security Health Education Standard of living Political participation Social engagement Physical security Sen AK. Development as freedom. New York: Anchor books, 1999. United Nations Development Programme. Human development report 2002: deepening democracy in a fragmented world. New York: Oxford University Press; 2002. UNDP Human Development Index

35. Choice and Non-Choice Levins R, Lopez C. Toward an ecosocial view of health. International Journal of Health Services 1999;29(2):261-93. “If we aim to affect health behavior, we have to examine the circumstance that generate behavior and understand the relation of choice to non-choice. Choices are always made from among alternatives presented by the social environment, or by circumstances that were themselves not chosen. Choice depends on the tools for making choices, the outer edge of people's aspirations as they have been encouraged or dampened by past experience. 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.”

36. Linking Living Conditions to Freedoms Healthy StateFreedom From…Selected Examples Physical securityPhysical extremes Crash, fire, fall Heat, cold Radiation Hazardous substances Natural disaster Infectious diseases PeaceViolence Homicide Suicide War Rape Minimal standard of living Deprivation Malnutrition Homelessness Poverty Joblessness Overcrowding Illiteracy Inadequate education Social engagementDisconnection Inequality Injustice Dependency Incarceration Runaway Neglect Stable organic processes Impaired metabolism Heart disease Cancer Stroke Diabetes Arthritis Obesity Mental/emotional balance Impaired cognition or emotion Depression Anxiety Attention deficit Lack of recreation Successful reproduction Impaired reproduction Infertility Miscarriage Birth defects Infant mortality

37. Areas of Emphasis Safer, Healthier Population Becoming Vulnerable Becoming no longer vulnerable Vulnerable Population Becoming Afflicted without Complications Developing Complications Afflicted with Complications Targeted protection Primary prevention Secondary prevention Dying from Complications Tertiary prevention Society's Health Response General protection Adverse Living Conditions World of Providing… Education Screening Disease management Pharmaceuticals Clinical services Physical and financial access Etc… Medical and Public Health Policy DISEASE AND RISK MANAGEMENT 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… Healthy Public Policy & Public Work DEMOCRATIC SELF-GOVERNANCE

38. Two Policy Orientations Adapted from: Hancock T. Beyond health care: from public health policy to healthy public policy. Can J Public Health 1985;76 Suppl 1:9-11. Healthy Public PolicyMedical and Public Health Policy Concerned chiefly with assuring safer, healthier conditions for all Concerned chiefly with preventing and alleviating specific diseases, managing complications, and delaying premature death or disability Relies heavily on multiple, small-scale, local solutions, with low technology Relies heavily on specific high-technology solutions, widely applied Combines analyses into a broad systems view, transcending sector boundaries Confines analyses to the health sector Future-oriented (reacting to long-term dynamics) Present-oriented (reacting to immediate events) Questions the givens, focuses on plausible outcomes Accepts the givens, focuses on probable outcomes Evaluated first through simulation, then through implementation Evaluated through implementation Main resources are citizen leadership and broad-based public work (including that of professionals) Main resources are money, professional expertise, and technology (often excluding citizen leadership)

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

40. Internal Focus “Let me assure you, we will survive any crisis that involves funding, political support, popularity, or cyclic trends, but we can't survive the internal crisis, if we become provincial, focus totally on the short term, or if we lose our philosophy of social justice.” -- William Foege Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.

41. For Additional Information http://www.cdc.gov/syndemics