1. Complex public health problems and syndemics : how can these theories guide our practice ?
PHPC CPD event, May 24th 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 How do we weave these concepts into our strategies?
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, comorbidities, 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
Coined in early 1990s by Merrill Singer, then by CDC, with Bobby Milstein (2008)
agent-agent interaction (ex HIV+TB)
social and human built environments
Interaction between these and host characteristics
Source : Merrill Singer, Introduction to Syndemics, Wiley ed. , 2009
« You think that if you understand 1,
you understand 2, because 1 and 1 are 2.
… but you must also understand "and."
Source : a Sufi saying, quoted in Milstein B., 2008

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
« You think that if you understand 1,
you understand 2, because 1 and 1 are 2.
… but you must also understand "and."
Source : a Sufi saying, quoted in Milstein B., 2008
Adapted from :

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
Pour répondre à cette question chaque personne a 10 minutes pour elle-même
On revient en plénière pour la discussion de cette question de telle sorte que tout le monde soit sur la même planète
Après la discussion, je présente les caractéristiques
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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
Brenda Zimmerman
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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
Brenda Zimmerman
We tend to manage PH problems as either simple or complicated, with best practices and experts
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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
Brenda Zimmerman
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16. Birds in flight follow 3 simple rules
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
The approach sprang from :
a strong sense of place, intense concern that residents of that place were unnecessarily vulnerable to multiple afflictions,
a passion for redirecting health futures in jeopardy, and
an unwavering attention to relationships among people, problems, and the possibilities for change
These led to public actions that simultaneously :
strengthened people’s power,
expanded people’s choices,
instituted norms of widespread accountability,
and ultimately transformed adverse living conditions
and the health indices that they engender

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
You will recognize principles of the Ottawa Charter, applied before it was charted

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
Source : System Dynamics and the Lessons of 35 Years
by Jay W. Forrester, Sloan School of Management, Massachusetts Institute of Technology
« The first step is to tap the wealth of information that people possess in their heads. The mental data base is a rich source of information about the parts of a system, about the information available at different points in a system, and about the policies being followed in decision making. The management and social sciences have in the past unduly restricted themselves to measured data and have neglected the far richer and more informative body of information that exists in the knowledge and experience of those in the active, working world. »
Mental data base : importance of dialogue, as proposed in the community development approaches to bottom up collaborative planning and development
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

23. Expanding Boundaries of Public Health Science
« innovators, in increasing numbers, are :
acknowledging the interdependency of people in places;
perceiving more of the dynamics that govern patterns of health, vulnerability, and affliction;
searching purposefully for the many plausible futures that could unfold; and/or
working democratically with other citizens to build the public strength needed for navigating change and expanding people’s freedoms. »
Source : Milstein 2008
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

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
« innovators, in increasing numbers, are :
acknowledging the interdependency of people in places;
perceiving more of the dynamics that govern patterns of health, vulnerability, and affliction;
searching purposefully for the many plausible futures that could unfold; and/or
working democratically with other citizens to build the public strength needed for navigating change and expanding people’s freedoms. »
Source : Milstein 2008
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
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
Ordered context
Fact based management
Cause and effect relationships are perceptible
Simple : best practices
Complicated : expertise (analyse)
Source : Snowden, Boone 2007 (HBR), p. 72

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 ! ”
Join in dialogues from 3 spheres of scholarship:
public health,
systems thinking and modeling, and
social navigation
PH leaders, community workers, health promoters, researchers, experts meet with, strategists, communicators, community members and other stakeholders to :
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

31. Adapt approach to the context
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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
Join in dialogues from 3 spheres of scholarship:
public health,
systems thinking and modeling, and
social navigation
PH leaders, community workers, health promoters, researchers, experts meet with, strategists, communicators, community members and other stakeholders to :
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, , pp
Complexity science, Complexity and clinical care, Tim Wilson, Tim Holt, BMJ, vol 323, , pp
Complexity science, Complexity, leadership, and management in healthcare organisations, Paul E Plsek, Tim Wilson, BMJ, vol 323, , pp
Complexity science, Coping with complexity: educating for capability. Sarah W Fraser, Trisha Greenhalgh, BMJ, vol 323, , pp
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36. References on Syndemics
Milstein B., Hygeia’s Constellation, CDC, Atlanta, 2008
Introduction to Syndemics: A Critical Systems Approach to Public and Community Health, Merrill Singer, Wiley ed. , 2009

37. References
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38. References
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39. References How Complexity Science is Transforming Healthcare
Brenda Zimmermanhttp://sig.uwaterloo.ca/feature/wici-seminar-applications-of-complexity-science-to-healthcare-brenda-zimmerman
How Complexity Science
is Transforming Healthcare
Brenda Zimmerman pp
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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 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 – document/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
Matta, Nadim F and Ashkenas, Ronald N., Why good projects fail anyway, Harvard Business Review, Sept 2003,

41. Merci !