1. Syndemics Prevention Network Directing Change and Charting Progress Toward Health Roles for System Dynamics and Social Navigation American Evaluation Association November 5, 2004 Atlanta, GA Jack Homer Homer Consulting Voorhees, New Jersey Bobby Milstein Centers for Disease Control and Prevention Atlanta, Georgia

2. Syndemics Prevention Network Navigating Health Futures "How do you know," I asked, "that in twenty years those things that you consider special are still going to be here?" At first they all raised their hands but when they really digested the question every single one of them put their hands down. In the end, there was not a single hand up. No one could answer that question…” -- Nainoa Thompson Thompson N. Reflections on voyaging and home. Polynesian Voyaging Society, 2001. Accessed July 18 at.

3. Syndemics Prevention Network Summers J. Soho: a history of London's most colourful neighborhood. Bloomsbury, London, 1989. p. 117. “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." Broad Street, One Year Later

4. Syndemics Prevention Network Public Health Goals Are Expanding …and Accumulating Prevent disease and injury (~1850 -- present) Promote health and 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

5. Syndemics Prevention Network Understanding Dynamic Complexity From a Very Particular Distance

6. Syndemics Prevention Network Health Protection as a Dynamic System Society's Health Response Demand for response Targeted Protection Safer Healthier People Becoming vulnerable Becoming safer and healthier Primary Prevention Vulnerable People Becoming afflicted Secondary Prevention Afflicted without Complications Developing complications Tertiary Prevention Afflicted with Complications Dying from complications Adverse Conditions General Protection Gerberding JL. CDC's futures initiative. Atlanta, GA: Public Health Training Network; April 12, 2004. Jackson DJ, Valdesseri R, CDC Futures Health Systems Work Group. Health systems work group report. Atlanta, GA: Centers for Disease Control and Prevention, Office of Strategy and Innovation; January 6, 2004. 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 Work Group; Atlanta, GA; December 3, 2003.

7. Syndemics Prevention Network A Dynamic System Out of Control Heirich M. Rethinking health care: innovation and change in America. Boulder CO: Westview Press, 1999. Pear R. Health spending rises to record 15% of economy. The New York Times 2004 January 9. The health sector now is one of the most consequential parts of the American economy, employing more people than any other area and tripling its share of the gross domestic product in the past 40 years.

8. Syndemics Prevention Network The U.S. Health System is Remarkably Resistant to Change Lee P, Paxman D. Reinventing public health. Annual Reviews of Public Health 1997;18:1-35. “At least six times since the Depression, the United States has tried and failed to enact a national health insurance program.” -- Lee & Paxman “Policy resistance is the tendency for interventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.” -- Meadows, Richardson, Bruckman

9. Syndemics Prevention Network Flaws in Previous Attempts at Health Reform in America 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. 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

10. Syndemics Prevention Network “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.” Rosnay J. The macroscope: a book on the systems approach. Principia Cybernetica, 1997.. -- Joèel de Rosnay Looking Through the Macroscope

11. Syndemics Prevention Network Seeing Beyond the Probable Possible What may happen? Plausible What could happen? Probable What will likely happen? Preferable What do we want to have happen? Bezold C, Hancock T. An overview of the health futures field. Geneva: WHO Health Futures Consultation; 1983 July 19-23. “Most organizations plan around what is most likely. In so doing they reinforce what is, even though they want something very different.” -- Ciement Bezold

12. Syndemics Prevention Network Re-Directing the Course of Change Questions from System Modeling and Social Navigation 20202010 How? Why? Where? Who? People with Diagnosed Diabetes, US 0 5 10 15 19801985199019952000 Million people Data Source: CDC DDT and NCCDPHP. -- Change in measurement in 1996.

13. Syndemics Prevention Network Different Modeling Approaches For Different Purposes Logic Models (flowcharts, maps or diagrams) System Dynamics (causal loop diagrams and simulation models) Forecasting Models Articulate steps between actions and anticipated effects Improve understanding about the plausible effects of a policy over time Focus on patterns of change over time (e.g., long delays, worse before better) Make accurate forecasts of key variables Focus on precision of point predictions and confidence intervals

14. Syndemics Prevention Network Time Series Models Describe trends Multivariate Stat Models Identify historical trend drivers and correlates Patterns Structure Events Increasing: Depth of causal theory Degrees of uncertainty Robustness for longer- term projection Value for developing policy insights Increasing: Depth of causal theory Degrees of uncertainty Robustness for longer- term projection Value for developing policy insights Dynamic Simulation Models Anticipate future trends, and find policies that maximize chances of a desirable path Tools for Navigational Analysis Developed by Jack Homer, Homer Consulting

15. Syndemics Prevention Network Learning Through Simulation Mission Ready 2004 “More than 100 CDC personnel from all levels of the organization participated in the Agency’s first ever full-scale internal emergency management exercise.” - CDC Connects May 6, 2004 Nellis K, Birch K. Mission ready 2004: this is a test. CDC Connects, Centers for Disease Control and Prevention, 2004.. “It’s important to exercise your plan before an event really happens…You need to validate your procedures. You need to see that the plan and reality are the same. It’s also a federal regulation to hold exercises. And it’s a good idea to get people thinking about their roles and how they will support the agency well before a crisis occurs.”

16. Syndemics Prevention Network Transforming the Future of Diabetes… "Every new insight into Type 2 diabetes... makes clear that it can be avoided--and that the earlier you intervene the better. The real question is whether we as a society are up to the challenge...Comprehensive prevention programs aren't cheap, but the cost of doing nothing is far greater..." Gorman C. Why so many of us are getting diabetes: never have doctors known so much about how to prevent or control this disease, yet the epidemic keeps on raging. how you can protect yourself. Time 2003 December 8. Accessed at http://www.time.com/time/covers/1101031208/story.html.http://www.time.com/time/covers/1101031208/story.html …in an Era of Epidemic Obesity

17. Syndemics Prevention Network Setting Realistic Expectations HP 2010 Diabetes Objectives Baseline HP 2010 Target Percent Change Reduce Diabetes–related Deaths Among Diagnosed (5-6) 8.8 per 1,000 7.8-11% Increase Diabetes Diagnosis (5-4) 68%80%+18% Reduce New Cases of Diabetes (5-2) 3.5 per 1,000 2.5-29% Reduce Prevalence of Diagnosed Diabetes (5-3) 40 per 1,000 25-38% U.S. Department of Health and Human Services. Healthy People 2010. Washington DC: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services; 2000. http://www.healthypeople.gov/Document/HTML/Volume1/05Diabetes.htm

18. Syndemics Prevention Network The Simple Physics of Diabetes It is impossible for any policy to reduce prevalence 38% by 2010! People with Undiagnosed Diabetes People with Diagnosed Diabetes Dying from Diabetes Complications Diagnosed Onset Initial Onset People with Normal Glycemic Levels As would stepped-up detection effort Reduced death would add further to prevalence With a diagnosed onset flow of 1.1 mill/yr And a death flow of 0.5 mill/yr (4%/yr rate) The targeted 29% reduction in diagnosed onset can only slow the growth in prevalence

19. Syndemics Prevention Network ReportedSimulated Status Quo Meet Detection Objective (5-4) Meet Onset Objective (5-2) HP 2010 Objective (5-3) HP 2000 Objective History and Futures for Diabetes Prevalence Reported Trends, HP Objectives, and Simulation Results A B C D E F G H I

20. Syndemics Prevention Network Diabetes System Modeling Project Where is the Leverage for Health Protection? People with Undiagnosed, Uncomplicated Diabetes People with Diagnosed, Uncomplicated Diabetes People with Diagnosed, Complicated Diabetes People with Undiagnosed PreDiabetes People with Diagnosed PreDiabetes People with Undiagnosed, Complicated Diabetes People with Normal Glycemic Levels Diagnosing Diabetes Diagnosing Diabetes Diabetes Detection Dying from Complications Developing Complications Diabetes Control PreDiabetes Detection Diagnosing PreDiabetes Diabetes Onset PreDiabetes Control Homer J, Jones A, Seville D, Essien J, Milstein B, Murphy D. The CDC diabetes system modeling project: developing a new tool for chronic disease prevention and control. 22nd International Conference of the System Dynamics Society; Oxford, England; 2004. PreDiabetes Onset Recovering from PreDiabetes Recovering from PreDiabetes Obesity Prevention

21. Syndemics Prevention Network Diabetes System Modeling Project Where is the Leverage for Health Protection? People with Undiagnosed, Uncomplicated Diabetes People with Diagnosed, Uncomplicated Diabetes People with Diagnosed, Complicated Diabetes Diagnosing Uncomplicated Diabetes People with Undiagnosed PreDiabetes People with Diagnosed PreDiabetes Diagnosing PreDiabetes Developing Complications from Undx diab Developing Diabetes from Undx PreD, People with Undiagnosed, Complicated Diabetes Diagnosing Complicated Diabetes Dying from Undx Complications People with Normal Glycemic Levels Diabetes Detection Obese Fraction of the Population Risk for PreDiabetes & Diabetes Caloric Intake Physical Activity PreDiabetes Control Diabetes Control PreDiabetes Detection Medication Affordability Ability to Self Monitor Clinical Management of PreDiabetes Adoption of Healthy Lifestyle Clinical Management of Diagnosed Diabetes Living Conditions Personal Capacity PreDiabetes Testing for Access to Preventive Health Services Testing for Diabetes PreDiabete s Onset Recovering from PreDiabetes Recovering from PreDiabetes Diabetes Onset Dying from Complications Developing Complications

22. Syndemics Prevention Network Using Available Data to Calibrate a Model Information SourcesData U.S. Census Adult population and death rates Health insurance coverage National Health Interview Survey Diabetes prevalence Diabetes detection National Health and Nutrition Examination Survey Prediabetes prevalence Weight, height, and body fat Caloric intake Behavioral Risk Factor Surveillance System Glucose self-monitoring Eye and foot exams Participation in health education Use of medications Professional Literature Physical activity trends Effects of control and aging on onset, progression, death, and costs Expenditures

23. Syndemics Prevention Network Confirming Fit to History Homer J, Jones A, Seville D, Essien J, Milstein B, Murphy D. The CDC diabetes system modeling project: developing a new tool for chronic disease prevention and control. 22nd International Conference of the System Dynamics Society; Oxford, England; 2004. Diagnosed Diabetes % of AdultsObese % of Adults

24. Syndemics Prevention Network What Drives the Burden of Diabetes? We Have Seen Two Primary Forces at Work Great Progress in Reducing the Burden for the Average Person with Diabetes Huge Growth in Number of People with Diabetes Overall, Total Population Burden Held at Bay

25. Syndemics Prevention Network Deaths Due to Diabetes per Capita Has Fallen Combine to mean fewer U.S. adults dying from diabetes per thousand! Complications Deaths per Thous People w Diabetes 40 30 20 10 0 198019851990199520002005 Time (Year) People with Diabetes per Thousand Adults 100 90 80 70 60 50 198019851990199520002005 Time (Year) More people with diabetes Deaths from Comps of Diabetes Per Thous Adults 2.5 2 1.5 1 0.5 0 198019851990199520002005 Time (Year) Among people with diabetes, fewer dying every year Model Output

26. Syndemics Prevention Network Anticipating the Future (1) Prevalence Under Status Quo Assumptions After a delay Obese Fraction of Adult Population 0.6 0.45 0.3 0.15 0 Even if we assume the obesity epidemic has peaked… People with Diabetes per Thousand Adults 130 110 90 70 50 19801990200020102020203020402050 Time (Year) Prevalence continues to increase. Model Output 19801990200020102020203020402050 Time (Year)

27. Syndemics Prevention Network And if we can maintain current levels of care but no continued improvement… If prevalence continues to increase, People with Diabetes per Thousand Adults 130 110 90 70 50 19801990200020102020203020402050 Time (Year) Complications Deaths per Thous w Diabetes 40 30 20 10 0 19801990200020102020203020402050 Time (Year) Deaths from Complications of Diabetes Per Thousand Adults 2.5 1.25 19801990200020102020203020402050 Time (Year) Then prevalence overwhelms the improved care to boost the burden Anticipating the Future (2) Deaths Under Status Quo Assumptions

28. Syndemics Prevention Network The Diabetes Learning Lab in Action

29. Syndemics Prevention Network How Strong Will Interventions Have to Be to Alter the Status Quo? People with Undiagnosed, Uncomplicated Diabetes People with Diagnosed, Uncomplicated Diabetes People with Diagnosed, Complicated Diabetes Diagnosing Uncomplicated Diabetes People with Undiagnosed PreDiabetes People with Diagnosed PreDiabetes Diagnosing PreDiabetes Complications from People with Undiagnosed, Complicated Diabetes Diagnosing Complicated Diabetes Complications People with Normal Glycemic Levels Diabetes Detection Obese Fraction of the Population Risk for PreDiabetes Caloric Intake Physical Activity PreDiabetes Control Diabetes Control PreDiabetes Detection Medication Affordability Ability to Self Monitor Clinical Management of PreDiabetes Adoption of Healthy Lifestyle Clinical Management of Diagnosed Diabetes PreDiabetes Testing for Access to Preventive Health Services Testing for Diabetes PreDiabetes Onset Recovering from PreDiabetes Recovering from PreDiabetes Diabetes Onset Dying from Complications Developing Complications

30. Syndemics Prevention Network Sketch the new future that would be created when…. Anticipating Change Over Time Lines can go off the graph area if you want (Status quo) Diagnosed Diabetes Population per Thousand (Status quo) Deaths from Complications of Diabetes per Thousand

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

32. Syndemics Prevention Network “Public health is probably the most successful system of science and technology combined, as well as social policy, that has ever been devised…It is, I think, a paradigmatic model for how you do concerned, humane, directed science.” -- Richard Rhodes Rhodes R. Limiting human violence: an emerging scientific challenge. Sarewitz D, editor. Living With the Genie: Governing Science and Technology in the 21st Century; New York, NY: Center for Science, Policy, and Outcomes; 2002. Hygeia’s Constellation Protecting Health Through Public Work

33. Syndemics Prevention Network Public work is sustained, visible, serious effort by a diverse mix of ordinary people that creates things of lasting civic or public significance. Mitchell Siporin. Jane Addams memorial. Illinois Federal Art Project, WPA, 1936. Fine Arts Collection, General Services Administration. Center for Democracy and Citizenship. The concept and philosophy of public work. Center for Democracy and Citizenship, 2001. Available at. What Exactly is Public Work?

34. Syndemics Prevention Network Widespread Interest in the Promise of a Systems Orientation See: http://www.cdc.gov/syndemics/ajph-systems.htm Submission Deadline: February 1, 2005