Seeing Syndemics

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Seeing Syndemics

• Thoughts on Improving Public Health in
  Communities Challenged by Multiple Afflictions

Bobby Milstein CDC Work in Progress
Seminar Emerging Investigations and Analytic
Methods July 18, 2002
2
Robert Wood Johnson Foundation. A portrait of the
chronically ill in America, 2001. Princeton, NJ
Robert Wood Johnson Foundation and the Foundation
for Accountability 2002. lthttp//www.rwjf.org/pub
lications/publicationsPdfs/report_chronic_illness.
pdfgt.
3
Populations at risk for one chronic disease are
often at risk for multiple chronic diseases, and
the risk factors underlying these diseases are
often similarPublic health research is
increasingly looking for and evaluating the
effectiveness of methods for integrating programs
and services to meet the interconnected needs of
populations.
-- National Center for Chronic Disease
Prevention and Health Promotion
See http//www.cdc.gov/nccdphp/agenda/index.htm
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DefinitionSyndemic
Two or more afflictions, interacting
synergistically, contributing to excess burden of
disease in a population.
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Syndemics Involve
The spread and persistence of mutually
reinforcing health problems typically found in
communities with unfavorable living conditions
(e.g., economic hardship, deteriorated
infrastructure, social disruption,
institutionalized racism, inadequate health care,
etc.)
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New Word for a Familiar Phenomenon
We have introduced the term syndemic to refer
to the set of synergistic or intertwined and
mutually enhancing health and social problems
facing the urban poor.  Violence, substance
abuse, and AIDS, in this sense, are not
concurrent in that they are not completely
separable phenomena.
-- Merrill Singer
Singer M. 1994. AIDS and the health crisis of
the US urban poor The perspective of critical
medical anthropology. Social Science and
Medicine 39(7) 931-948. Singer M. 1996. A dose
of drugs, a touch of violence, a case of AIDS
Conceptualizing the SAVA syndemic. Free Inquiry
in Creative Sociology 24(2) 99-110.
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Picture a Community Where

• Conditions are not supportive of healthy living
• People are either afflicted by or at risk for
  mutually reinforcing health problems
• Community leaders are making an effort to fight
  the afflictions and improve living conditions,
  but their capacity to do so is limited
• More could be done with backing from government
  and philanthropies

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Your Mission
Assure the conditions in which people can be
healthy

• Improve health
• Enhance living conditions
• Strengthen capacity

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DefinitionHealth
A state of complete physical, social and mental
well-being, and not merely the absence of disease
or infirmity.
-- World Health Organization
World Health Organization. Health promotion
glossary. World Health Organization, 1998.
Accessed July 15 at lthttp//www.who.int/hpr/docs/g
lossary.htmlgt.
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DefinitionLiving Conditions
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
World Health Organization. Health promotion
glossary. World Health Organization, 1998.
Accessed July 15 at lthttp//www.who.int/hpr/docs/g
lossary.htmlgt.
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Prerequisite Conditions

• Peace
• Shelter
• Education
• Food

• Income
• Stable eco-system
• Sustainable resources
• Social justice and equity

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
lthttp//www.who.int/hpr/archive/docs/ottawa.htmlgt.
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DefinitionCapacity for Action
The ability of individuals and organizations
to apply their skills and resources in collective
efforts to address health priorities and meet
their respective health needs.
-- World Health Organization
World Health Organization. Health promotion
glossary. World Health Organization, 1998.
Accessed July 15 at lthttp//www.who.int/hpr/docs/g
lossary.htmlgt.
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Starting Assumptions

• Effective responses to complex community health
  problems require system-wide interventions
• Most public health agencies act as if each
  affliction can be prevented individually by
  understanding its unique causes and developing
  targeted interventions
• This compartmentalized approach is engrained in
  financial structures, problem solving frameworks,
  statistical models, and criteria for professional
  prestige

How will you proceed?
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The Approach Ought to Be

• Ecological
• Collaborative
• Evidence-based
• Ethical
• Others?

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How would we proceed using a syndemic orientation?
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Caveats

• Work in progress
• Case studies have yet to begin
• Another in a class of ecological models
• Not new, but a novel way of combining
  longstanding public health traditions with
  theories and methods from other applied sciences
• Open to evolve in many directions

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DefinitionSyndemic 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.
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Spectrum of Prevention
Time Horizon for Observing Effects on Population
Health Status
SHORTmonths-years
LONGdecades-centuries
INTERMEDIATEyears-decades
Effects on outcomes other than population
health status (e.g., risk/protective behaviors,
change agents, or system changes) can be observed
in shorter time intervals
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What problems have surfaced using conventional
approaches?
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Recurring Evaluation Challenges

• Linking comprehensive interventions to
  categorical disease outcomes

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Balancing Values
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Mismatch Between Gold Standard Intervention and
Evaluation
Attributes of Interventions Associated with Effectiveness Attributes of Interventions Associated with Evaluability
significant front-line flexibility standardized discretion minimized
evolving, in response to experience and changing conditions constant over time
intervention/program design reflecting local strengths, needs, preferences intervention/program centrally designed, uniform across sites
intake/recruitment into program under local control within broad parameters intake/recruitment into program centrally designed to permit random assignment
multi-factor single factor
interactive components components clearly separable
emphasize continuity of respectful relationships, other hard-to-measure inputs readily measured inputs
implementers believe in the intervention value-free implementation
Source Schorr LB. Common purpose strengthening
families and neighborhoods to rebuild
America. New York, NY Doubleday, Anchor Books,
1997.
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Recurring Evaluation Challenges

• Linking comprehensive interventions to
  categorical disease outcomes
• Leaps of faith leading to overall health
  improvement

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Logical Links?
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Goals Have a Nested Structure

• Disease Prevention
• Prevent disease and injury

• Health Promotion
• Prolong length
• Improve quality
• Eliminate disparity
• Enhance satisfaction

• Public Health
• Assure the conditions for health for all

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Recurring Evaluation Challenges

• Linking comprehensive interventions to
  categorical disease outcomes
• Leaps of faith leading to overall health
  improvement
• Side effects of specialization

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Side Effects of Specialization

• Noise
• Inefficiency
• Competition
• Coercive power dynamics
• Neglected feedback ( and -)
• Confounded evaluations
• Limited mandate to address living conditions
• Disappointing track record

Community
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Diseases of Disarray

• 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.
19933(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 199283(5)326-8.
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Outlook for Future Effectiveness
Afflictions Under Control
1850
2100
2000
Year
That is for certain subgroups except in the
case of smallpox, no afflictions have been
controlled equitably
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Sword in the Stone
What problem solving strategy is appropriate for
assuring the conditions in which people can be
healthy?
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Brief History of Public Health Problem
SolvingWhat accounts for poor community health?

• Gods will
• Humors, miasma, ether
• Poor living conditions, immorality (sanitation)
• Single disease, single cause (germ theory)
• Single disease, multiple causes (CVD)
• Single cause, multiple diseases (tobacco)
• Multiple causes, multiple diseases (but no
  feedback dynamics) (social epidemiology)
• Dynamic feedback among afflictions, living
  conditions, and community capacity (syndemic)

1840
1880
1950
1960
1980
2000
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The Feedback Thought
When X and Y affect each other one cannot
study the link between X and Y and,
independently, the link between Y and X and
predict how the system will behave. Only the
study of the whole system as a feedback system
will lead to correct results."
-- System Dynamics Society
From http//www.systemdynamics.org/ See also
Richardson GP. Feedback thought in social science
and systems theory. Philadelphia University of
Pennsylvania Press, 1991.
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How would our health promotion venture operate
under a syndemic orientation?
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Conventional Problem Solving Approach

• Identify disease
• Determine causes
• Develop and test interventions
• Implement programs and policies

• Repeat steps 1-4, as necessary!

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Steps in a Syndemic Approach

• Identify community
• Cooperate with community members in
• Identifying afflictions and their relationships
• Examining living conditions and why they differ
• Devising beneficial system-wide policies
• Strengthening capacity to act
• Advocating for directed social change to assure
  the conditions for health for all
• Expand to other communities, as necessary

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Core Public Health Functions Under a Syndemic
Orientation
ASSESSMENT
SocialNavigation
NetworkAnalysis
CategoricalOrientation
SyndemicOrientation
System Dynamics
POLICYDEVELOPMENT
ASSURANCE
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Focus on Relational Questions and Relational Data
AssessmentNetwork Analysis Policy DevelopmentSystem Dynamics AssuranceSocial Navigation
What links to what? What influences what? What policies have the greatest leverage? What backlash could occur? Where are we going? Where are we now? How close are we? Where can we go from here?
Proximity Data Feedback Data Navigational Data
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Assessment
You think you understand two because you
understand one and one. But you must also
understand and. -- Sufi Saying
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Policy Development
The future is not to be predicted, but
created. -- Arthur C. Clarke

• Maximize all three parts of the mission health,
  living conditions, and capacity
• Explicit model building
• Simulated experiments
• What if
• What futures are possible?
• Real world action and observation

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Tools for Policy Development
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Preliminary Dynamic Model Under What Conditions
Do Syndemics Emerge? How Can they be Controlled?
Affliction
prevalence
Community
capacity
General
community
conditions
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Preliminary Dynamic Model Under What Conditions
Do Syndemics Emerge? How Can they be Controlled?
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Web-based Simulation Gamehttp//broadcast.forio.c
om/sims/syndemic/
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Web-based Simulation Gamehttp//broadcast.forio.c
om/sims/syndemic/
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Web-based Simulation Gamehttp//broadcast.forio.c
om/sims/syndemic/
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Web-based Simulation Gamehttp//broadcast.forio.c
om/sims/syndemic/
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Web-based Simulation Gamehttp//broadcast.forio.c
om/sims/syndemic/
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Assurance
The path resounds to our footfall, but do we
have it in ourselves to change
direction? -- Peter Ustinov

• Implement policies by aligning health with other
  avenues of social change
• Advocacy driven by community leaders in
  partnership with health professionals
• Navigational perspective, guided by community
  vision and values
• Forward orientation
• Adapts to changing conditions

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Formalize Navigational Imagery
See NACCHO website http//nacchoweb.naccho.org/M
APP_Home.asp
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Basic Concepts in Navigational Science

• Position (current state)
• Destination (goals, values)
• Direction (chosen course)
• Distance (difference from goal)
• Drift (deflection from course)
• Set (distance to get back on course)
• Conditions (physical, historical or evolutionary
  context)

• Time
• Energy
• Resistance
• Alignment
• Navigational aids
• Charting

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Selected Navigational Statistics
Adapted from Baker RR. Human navigation and the
sixth sense. New York, NY Simon and Schuster.
1981. Oriana website http//www.kovcomp.co.uk/ori
ana/
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Selected Navigational Statistics
Group comparisons are possible, but not required
Adapted from Baker RR. Human navigation and the
sixth sense. New York, NY Simon and Schuster.
1981. Oriana website http//www.kovcomp.co.uk/ori
ana/
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Planning the Voyage
"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 lthttp//leahi.kcc.hawaii.edu/org/pvs/malama/
voyaginghome.htmlgt.
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Charting the Course for Social Change
A Healthy Natural Environment (10 indicators)
A Safe, Nurturing Social Environment (14
indicators)
A Thriving, Diverse, Sustainable Economy (15
indicators)
Educated Citizens (8 indicators)
Civic Vitality (5 indicators)
Hawai'i Community Services Council. Ke Ala Hoku
critical indicators report. Honolulu Hawai'i
Community Services Council, 1999. See
http//www.hcsc-hawaii.org/kah/index.htm
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Implications

• Builds upon established theories and methods
• Complements single-issue prevention strategies
• Offers simulation modeling as an alternative to
  experimenting with comparison or control groups
• Adheres to a navigational perspective that
  strengthens leadership and sharpens science
• Fosters essential partnerships (between public
  and professionals within public health across
  sectors)
• Advances a specific course of social change, one
  focused on unifying health, development, justice,
  and self-determination.

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Syndemic Network Members in the US
http//www.cdc.gov/syndemics

• International
• Argentina
• Australia
• Canada
• Grenada

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For Additional Information http//www.cdc.gov/synd
emics