1. Complex public health problems and syndemics : how can these theories guide our practice ? PHPC CPD event, May 24 th 2015 Vancouver Odette Laplante, MD, MSc, CSPQ, FRCPC Médecin conseil, CISSS Chaudière-Appalaches Yv Bonnier-Viger, MD, MSc, MM, CSPQ, FRCPC Directeur, DMSP, U Laval

2. PRESENTER INFORMATION ON CONFLICTS OF INTEREST The authors of this presentation have no relationship with a commercial entity such as a pharmaceutical organization, medical device company or a communications firm nor other known conflicts of interest related to this presentation

3. LEARNING OBJECTIVES By the end of this session, participants will : Recognize dimensions of complex problems and “syndemics” Analyze how they apply to public health practice Adapt strategies to public health issues and challenges Competencies addressed : Act as a more effective consultant, partner, leader, to : – investigate and mitigate risks, – guide a strategic context analysis of public health issues – based on often omitted dimensions of public health issues

4. PRESENTATION PLAN Introduction Syndemics Complex issues and systems dynamics Lessons for PH practice Questions for group discussion Plenary and conclusion

5. INTRODUCTION We know : multi causality of avoidable disease and injury each factor influences several problems  integrated approaches are more effective public health problems are often complex,  woven in with social, economic, political issues so other sectors share same problems and determinants How do we weave these concepts into our strategies? On what scientific basis ?

6. SYNDEMICS

7. SYNERGISTIC EPIDEMICS Definition : 2 or more afflictions, – interacting synergistically, mutually enhancing – contributing to excess burden of disease in a population Related concepts : linked epidemics, interacting epidemics, connected epidemics, co-occurring epidemics, co morbidities, and clusters of health-related crises, wicked problems Source : Introduction to Syndemics: A Critical Systems Approach to Public and Community Health, Merrill Singer, Wiley ed., 2009

8. INFLUENCES ON DISEASE CLUSTERING AND INTERACTION agent-agent (ex HIV+TB) social and human built environments between these and host characteristics …and with the vectors Source : Merrill Singer, Introduction to Syndemics, Wiley ed., 2009 Adapted from : https://onlinecourses.science.psu.edu/stat507/print/book/export/html/25

9. EXAMPLES OF SOCIAL AND HEALTH SYNDEMICS Contagious urban decay / deterioration in NYC (~1969) – trigger: fire services were removed and rearranged under the policy of planned shrinkage – impact on public health and public order – a self-reinforcing and interactive mix Wallace D, Wallace R, 1998 Substance abuse, violence and AIDS syndemic – intertwined and mutually enhancing health and social problems facing the urban poor – not « concurrent » (separable) phenomena Singer M, Romero-Daza N. 1997

10. COMPLEX (SOMETIMES WICKED) ISSUES AND SYSTEMS DYNAMICS

11. CERTAINTY-AGREEMENT DIAGRAM

12. SIMPLE PROCESS Can be managed with a recipe : – specifies ingredients (type & quantity) – produces a known reproducible result – no high expertise required The result is always the same The world of the « known » The realm of best practices Adapted from Brenda Zimmerman

13. COMPLICATED PROCESS Plans are essential – division in small parts with coordination – using the same plan : all vessels look alike good chance of same result 1 success increases chance of others High level expertise and collaboration The world of the « possible to know » The domain of experts Adapted from Brenda Zimmerman

14. COMPLEX ADAPTIVE SYSTEM Definition : A set of agents, free to act in a not totally expectable manner, whose actions are interconnected in a way that the actions of one agent change the context for the other agents

15. COMPLEX PROCESS Each child is unique The outcome is uncertain Can’t separate parts from the whole Interactions (synergies) are non linear – minor changes can produce disproportionately large consequences Plans have limited value One success doesn’t predict the next Expertise helps, but is insufficient Relations are key We are in the « unknown », Domain of “emergence” and pattern recognition Adapted from Brenda Zimmerman DRSPCA - DMSPUL - Yv

16. BIRDS IN FLIGHT FOLLOW 3 SIMPLE RULES http://gestion-des-risques-interculturels.com/wp-content/uploads/2013/03/nuees-oiseaux.jpg Separation : avoid touching their neighbour Alignment : follow their neighbour’s direction Cohesion : position themselves among their neighbours

17. HOW CAN WE APPLY THESE PRINCIPLES TO PUBLIC HEALTH PRACTICE ?

18. THE NORTH KARELIA CVD EPIDEMIC

19. THE NORTH KARELIA CVD EPIDEMIC STORY Sprang from : a strong sense of place, intense concern that residents were unnecessarily vulnerable to multiple afflictions, a passion for redirecting health futures in jeopardy, attention to relationships among people, problems and the possibilities for change Public actions simultaneously : strengthened people’s power, expanded people’s choices, instituted norms of widespread accountability, ultimately transformed adverse living conditions – and the health indices that they engender

20. TOOLS TO DIAGNOSE A COMPLEX OR SYNDEMIC ISSUE

21. DATA SOURCES TO DESCRIBE (AND MODEL) SYSTEMS : GATHERED AND ORGANISED BY DIALOGUE Data = information material serving as a basis for discussion, inference, or determination of policy detailed information of any kind Webster's Third, Unabridged JW Forrester, Systems Dynamics and the Lessons of 35 years, chapter 7 in : The systemic Basis of Policy Making in the 1990s, 1991

22. FIELDS SHAPING INNOVATIVE HEALTH VENTURES Source : Hygeia’s Constellation : Navigating health futures in a dynamic and democratic world, Bobby Milstein, Centers for Disease Control and Prevention, 2008, p. 9 http://www.cdc.gov/syndemics/monograph/index.htm

23. EXPANDING BOUNDARIES OF PUBLIC HEALTH SCIENCE Source : Milstein, Hygeias constellation, 2008

24. BUILD A CAUSAL LOOP DIAGRAM Source : CDC, Syndemics prevention network, Neighborhood Transformation Game: Making the Most of Temporary Assistance, 2006 http://www.cdc.gov/syndemics

25. STEPS IN SYSTEM DYNAMICS MODELING Source : Hygeia’s Constellation : Navigating health futures in a dynamic and democratic world, Bobby Milstein, Centers for Disease Control and Prevention, 2008

26. EXPANDING BOUNDARIES OF PUBLIC HEALTH SCIENCE Source : Milstein, Hygeias constellation

27. TOOLS TO MANAGE AND IMPLEMENT IN A COMPLEX CONTEXT

28. « Wise executives tailor their approach to fit the complexity of the circumstances they face » Managing collaboration is managing connectivity Relationships are key to the functioning of a complex system – provide connections between the components of the system – as synapses between neurons Source : Snowden, David F., Mary E. Boone, 2007

29. ADAPT ACTION TO THE CONTEXT : THE CYNEFIN FRAMEWORK Source : Snowden, Boone 2007 (HBR), p. 72 Ordered context Fact based management Cause and effect relationships are perceptible Simple : best practices Complicated : expertise (analyse) Unordered world Complex or chaotic situations : Emerging problems : often complex Patterns : no immediately apparent cause-effect relationship Pattern based management Disorder : Break the situation in parts Assign each to 1 of 4 realms Adapt management to each Chaos : requires rapid response

30. LEADING IN A COMPLEX CONTEXT: IMPORTANCE OF PROCESS Open up the discussion, dialogue, involve agents Set barriers : barriers, simple rules limit or delineate behaviour (ex. fish banks) Stimulate attractors, incentives : incite action towards a new trend Encourage dissent and diversity : competing ideas and approaches Manage starting conditions Monitor for emergence and changes and adapt : “ Houston, we have a problem ! ”

31. ADAPT APPROACH TO THE CONTEXT

32. QUESTIONS FOR DISCUSSION AROUND AN EXAMPLE Are these examples of simple, complicated, complex, chaotic or disordered situations ? Why ? Was the diagnosis step well adapted ? Were the solution and plan well adapted ? Was the leadership / management style adapted ? What lessons learned ? What competencies would we need to develop ? Suggestions and comments ?

33. MANAGING COMPLEX ISSUES Dialogues from 3 spheres of scholarship:  public health,  systems thinking and modeling, and  social navigation Develop a common understanding of the problem  Using qualitative and quantitative sources and skills Define a common vision and actions  Based on principles of democracy, empowerment and innovation Adapt services and empower multipronged changes

34. CONCLUSION We have all done it intuitively or otherwise on small scales Acting at this system-wide scale, however, requires thinking differently about public health work itself.

35. REFERENCES Complexity science, The challenge of complexity in health care, Paul E Plsek, Trisha Greenhalgh. BMJ, vol 323, 2001-9- 15, pp. 625-8 Complexity science, Complexity and clinical care, Tim Wilson, Tim Holt, BMJ, vol 323, 2001-9-22, pp. 685-8 Complexity science, Complexity, leadership, and management in healthcare organisations, Paul E Plsek, Tim Wilson, BMJ, vol 323, 2001-9-29, pp. 746-9 Complexity science, Coping with complexity: educating for capability. Sarah W Fraser, Trisha Greenhalgh, BMJ, vol 323, 2001-10-6, pp. 799-803

36. REFERENCES ON SYNDEMICS Introduction to Syndemics: A Critical Systems Approach to Public and Community Health, Merrill Singer, Wiley ed., 2009 Milstein B., Hygeia’s Constellation, CDC, Atlanta, 2008

37. REFERENCES

38. DRSPCA - DMSPUL - Yv38 REFERENCES

39. How Complexity Science is Transforming Healthcare Brenda Zimmerman pp. 617-635 REFERENCES Brenda Zimmerman http://sig.uwaterloo.ca/featur e/wici-seminar-applications- of-complexity-science-to- healthcare-brenda- zimmerman http://sig.uwaterloo.ca/featur e/wici-seminar-applications- of-complexity-science-to- healthcare-brenda- zimmerman

40. OTHER KEY REFERENCES Levy et al., Simulation Modeling and Tobacco Control: Creating More Robust Public Health Policies. American Journal of Public Health | March 2006, Vol 96, No. 3 Snowden, David F., Mary E. Boone 2007. A Leader’s Framework for Decision Making: Wise executives tailor their approach to fit the complexity of the circumstances they face. Harvard Business Review (November): 70 – 76 https://www.mentalhealthcommission.ca/English/system/files/private/do cument/Primary_Care_Article_4_Gervais_ENG.pdf https://www.mentalhealthcommission.ca/English/system/files/private/do cument/Primary_Care_Article_4_Gervais_ENG.pdf JW Forrester, Systems Dynamics and the Lessons of 35 years, 1991, chapter 7 in : The systemic Basis of Policy Making in the 1990s http://link.springer.com/chapter/10.1007/978-1-4615-3226-2_7#page-1 http://link.springer.com/chapter/10.1007/978-1-4615-3226-2_7#page-1 Matta, Nadim F and Ashkenas, Ronald N., Why good projects fail anyway, Harvard Business Review, Sept 2003, https://hbr.org/2003/09/why-good-projects-fail-anyway https://hbr.org/2003/09/why-good-projects-fail-anyway

41. MERCI !