syndemics prevention network the dynamics of upstream and downstream cdc futures health systems...

Syndemics

Prevention Network

The Dynamics of Upstream and Downstream

CDC Futures Health Systems Workgroup

December 3, 2003

Bobby MilsteinSyndemics Prevention Network, CDC

[email protected]

http://www.cdc.gov/syndemics

Jack HomerHomer Consulting

[email protected]

http://www.homerconsulting.com

Why is it so hard for the public health system to work upstream, and what can be done about it?

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Public Health Effort Across the Chain

Upstream Prevention and Protection-----------------------------------Total 3%

Downstream Care and Management--------------------------------Total 97%

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The Simple Physics of Upstream and Downstream

Safer, Healthier

Population Becomingvulnerable

Becoming no longervulnerable

VulnerablePopulation

BecomingAfflicted

Afflictedwithout

Complications DevelopingComplications

Afflicted withComplications

Dying fromComplications

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Why focus on “affliction”?

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Focusing on disease prevention and control

has led to major achievements

600

500

400

200

100

501950 1960 1970 1980 1990 1995

Rate if trend continued

Peak Rate

Actual Rate

Age-a

dju

sted D

eath

Rate

per

10

0,0

00

Popula

tion

1955 1965 1975 1985

300

700

Year

Actual and Expected Death Rates for Coronary Heart Disease, 1950–1998

Marks JS. The burden of chronic disease and the future of public health. CDC Information Sharing Meeting. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion; 2003.

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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 <http://apps.nccd.cdc.gov/HRQOL/>.

But the pictures look different when we examine people’s overall state of health or affliction

14% increase

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Why Do We Do Public Health Work?What is the System Organized to Do?

CDC Vision & Mission

Healthy people, in a healthy world, through prevention

To promote health and quality of life by preventing and controlling

disease, injury, and disability

CDC Vision & Mission

Healthy people, in a healthy world, through prevention

To promote health and quality of life by preventing and controlling

disease, injury, and disability

Institute of Medicine

The purpose of public health is to fulfill society’s interest in

assuring the conditions in which people can be healthy

Institute of Medicine

The purpose of public health is to fulfill society’s interest in

assuring the conditions in which people can be healthy

How we reconcile these two frames of reference will shape the possibilities for what we can accomplish in leading health system change.

A systems approach understands that both perspectives exist in a dynamic relationship with each other.

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“When we attribute behavior to people rather than system structure the focus of management becomes

scapegoating and blame rather than the design of organizations in which ordinary people can achieve

extraordinary results.”

-- John Sterman

Sterman J. System dynamics modeling: tools for learning in a complex world. California Management Review 2001;43(4):8-25.

Why Has it Been So Hardto Correct the Imbalance?

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more inter-organizationally complex, slower rate of improvement

organizationally complex, faster rate of improvement

What Kinds of Work Must the Public Health System Perform?

Public Work (organizing, governance, citizenship, mutual accountability)

Professional Work (customers, products, services)

FOR SELF INTEREST FOR OTHERS IN NEED

Safer,Healthier

Population BecomingVulnerable

Becoming nolonger vulnerable

VulnerablePopulation Becoming

Afflicted

Afflictedwithout



Targetedprotection

Primaryprevention

Secondaryprevention


Tertiaryprevention

Society's HealthResponse

Generalprotection

Adverse LivingConditions

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“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.”

-- Bill Foege

Foege WH. Public health: moving from debt to legacy. American Journal of Public Health 1987;77(10):1276-8.

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Beyond the Obvious Morality of it, Why Place So Much Emphasis on Social Justice?

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What Drives Change Across the Chain?


BecomingAfflicted

Afflictedwithout




Safer, Healthier

Population Becomingvulnerable

Becoming no longervulnerable

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Upstream and Downstream Work

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout

ComplicationsBecomingafflicted


Developingcomplications


Downstream/Professional work

Professionalconcern

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Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onprogression

-

Effect oncomplications

-

TertiaryPrevention

SecondaryPrevention


Professionalconcern

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Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout






-


-

TertiaryPrevention

SecondaryPrevention

Vulnerable andAfflicted Popn

Upstream/Public work


Professionalconcern

Publicconcern

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Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-

Effect onvulnerabilityreduction

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention




Professionalconcern

Publicconcern

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Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-

Effect on livingconditions


GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention




Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

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Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention




Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

Citizen Involvementand Organizing

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Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention




Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-


SocialDivision

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Downstream lock-in: Delay in upstream effort guarantees continued growth in affliction, need for downstream effort and, hence, dependency on professionals, which further undermines upstream effort, as does mounting social disparity.

Safer,Healthier

Population


Becomingvulnerable


Afflictedwithout





Effect onincidence

-


-


-



GeneralProtection

TargetedProtection

TertiaryPrevention

SecondaryPrevention

PrimaryPrevention




Professionalconcern

Publicconcern

AdverseLiving

Conditions

-

PublicStrength

SocialDisparity

-


SocialDivision

-

Dependency onProfessionals

Citizen exclusionand complacency

-

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Dynamic Models Let Us Search for Policies That Leverage Public Work

• Computer technology makes it feasible to put system maps in motion, to learn how health patterns change under different conditions, and to seriously evaluate or rehearse the long-term effects of response options: they provide added foresight

• Such models open new avenues for domestic and global problem solving, systems research, knowledge integration, game-based learning, as well as richer dialogue among stakeholders

Prototype of a health system simulation model

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CDC’s Strength Lies in Leading Public Work

• CDC’s credibility and effectiveness rest on more than scientific excellence

• The agency’s reputation also stems from the widespread perception that CDC is an organization of talented people working to protect us all: a people’s institution

• If CDC comes to be viewed primarily as a provider of products/services to customers in need, it could erode leadership potential for upstream action

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SummaryWhy is it So Hard to Work Across the Whole System?

Initial Observations

• Upstream work requires more public concern, which is less a reaction to the prevalence of disease as to the spread of vulnerability and affliction that over many years threaten everybody (think of economic decline, inadequate education, unsafe housing, sprawl, racism, environmental decay, etc.)

• Long before upstream threats become widely apparent, money and other resources have focused downstream (where professional expertise and the weight of scientific evidence lie)

• Because of their role as providers of downstream services, health professionals do not respond to vulnerability and social disparity FOR ITS OWN SAKE, in the WAY that ordinary citizens often do

• Upstream health action involves broad-based organizing; it is political—but non-partisan—and cannot be done by professionals alone.

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"The people's health...is a concern of the people themselves. They

must want health. They must struggle for it and plan for it.

Physicians are merely experts whose advice is sought in drawing up

plans and whose cooperation is needed in carrying them out. No

plan, however well devised and well intentioned, will succeed if it is

imposed on the people. The war against disease and for health

cannot be fought by physicians alone. It is a people's war in which

the entire population must be mobilized permanently."

Sigerist, HE. Health. Journal of Public Health Policy., 1996 17(2): 204-234.

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Prototype of a Dynamic Simulation Model

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Steps For Putting the Map in Motion

• Start with an explicit dynamic hypothesis (i.e., what causal forces are at work?)

• Convert that hypothesis into a formal computer model (i.e., by writing a system of differential equations; and calibrating it based on all available data; areas of uncertainty are noted and become the focus for sensitivity analysis)

• Use the computer model to conduct controlled simulation studies, with the goal of learning how the system behaves and how to govern its evolution over time

• Iteratively repeat the process, creating better hypotheses, better models, and better policy insight

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Building a Dynamic Hypothesis

GeneralPopulation Vulnerability

onset

Vulnerabilityreduction

VulnerablePopulation Affliction

incidence

Afflictedwithout

Complications Afflictionprogression

afflicted percent of

Public healthresponse

Complicated

popn

-

General protectioneffect on vulnerability

onset

B General Protection

Targeted protectioneffect on vulnerability

reduction

B Targeted Protection


Death fromComplications

-

Secondary preventioneffect on progression

B

SecondaryPrevention

Primary preventioneffect on incidence

-

B

Primary Prevention

Tertiary preventioneffect on

complications

-

B

Treatment

Note: for this initial model, the system being modeled includes only a subset of the dynamics that were identified in the conceptual map.

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Could the behavior of this system be modeled using conventional epidemoiological methods (e.g., logistic or multi-level regression)?

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Active Equations (01) Afflicted = Afflicted without Complications + Afflicted with Complications

(02) Afflicted with Complications = INTEG( Affliction progression - Death from Complications , 0)

(03) Afflicted without Complications = INTEG( Affliction incidence - Affliction progression , 0)

(04) Affliction incidence = Vulnerable Popn * Affliction incidence rate baseline * Primary prevention effect on incidence

(05) Affliction incidence rate baseline = 0.05

(06) Affliction progression = Afflicted without Complications * Affliction progression rate baseline * Secondary prevention effect on progression

(07) Affliction progression rate baseline = 0.1

(08) Complicated afflicted percent of popn = 100 * Afflicted with Complications / Total popn

(09) Complicated afflicted percent required to elicit maximum PH response = 20

(10) Complicated percent of afflicted = 100 * ZIDZ ( Afflicted with Complications , Afflicted )

(11) Complications death rate baseline = 0.1

Writing Differential Equations

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(12) Death from Complications = Afflicted with Complications * Complications death rate baseline * Tertiary prevention effect on complications

(13) General Popn = INTEG( Net increase in genl popn + Vulnerability reduction - Vulnerability onset , Total popn initial * ( 100 - Vulnerable percent initial ) / 100)

(14) General protection effect from max PHR = 0.5

(15) General protection effect on vulnerability onset = 1 - ( 1 - General protection effect from max PHR ) * Public health response / 100

(16) Net increase in genl popn = Death from Complications * ( 1 - Vulnerable percent of nonafflicted / 100)

(17) Net increase in vulnerable popn = Death from Complications * Vulnerable percent of nonafflicted / 100

(18) Nonafflicted = General Popn + Vulnerable Popn

(19) Primary prevention effect from max PHR = 0.5

(20) Primary prevention effect on incidence = 1 - ( 1 - Primary prevention effect from max PHR ) * Public health response / 100

(21) Public health response = DELAY1I ( 100 * MIN ( 1, Complicated afflicted percent of popn / Complicated afflicted percent required to elicit maximum PH response ) , Time for public health to respond to affliction prevalence , 0)


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(22) Secondary prevention effect from max PHR = 0.5

(23) Secondary prevention effect on progression = 1 - ( 1 - Secondary prevention effect from max PHR ) * Public health response / 100

(24) Targeted protection effect from max PHR = 2

(25) Targeted protection effect on vulnerability reduction = 1 + ( Targeted protection effect from max PHR - 1) * Public health response / 100

(26) Tertiary prevention effect from max PHR = 0.5

(27) Tertiary prevention effect on complications = 1 - ( 1 - Tertiary prevention effect from max PHR ) * Public health response / 100

(28) Time for public health to respond to affliction prevalence = 2

(29) Total popn = Nonafflicted + Afflicted

(30) Total popn initial = 100000

(31) Vulnerability onset = General Popn * Vulnerability onset rate baseline * General protection effect on vulnerability onset

(32) Vulnerability onset rate baseline = 0.05


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(33) Vulnerability reduction = Vulnerable Popn * Vulnerability reduction rate baseline * Targeted protection effect on vulnerability reduction

(34) Vulnerability reduction rate baseline = 0.07

(35) Vulnerable percent initial = 10

(36) Vulnerable percent of nonafflicted = 100 * Vulnerable Popn / Nonafflicted

(37) Vulnerable Popn = INTEG( Net increase in vulnerable popn + Vulnerability onset - Affliction incidence - Vulnerability reduction , Total popn initial * Vulnerable percent initial / 100)


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Parameter Assumption

Population Characteristics

• Total population initially 100,000

• Percent afflicted initially 0%

• Percent vulnerable initially 10%

Developing Assumptions For Response Scenarios

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Baseline Epidemiological Characteristics

• Vulnerability onset rate (% per year among general pop) 5%

• Vulnerability reduction rate (% per year among vulnerable) 7%

• Affliction incidence rate (% per year among vulnerable) 5%

• Affliction progression rate (% per year among afflicted without complications)

10%

• Complications death rate (% per year among afflicted with complications)

10%


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Public Health System Characteristics

• Complicated affliction prevalence required to elicit maximum public health response (lower prevalence elicits proportionally smaller response)

20%

• Time for organizing a public health response to complicated affliction prevalence

2 years


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Effect of Public Health Responses

• Tertiary prevention effect on deaths from complications ?

• Secondary prevention effect on affliction progression ?

• Primary prevention effect on affliction incidence ?

• Targeted protection effect on vulnerability reduction ?

• General protection effect on vulnerability onset ?

Making Decisions About How to Respond

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Response Scenario

Effect of Public Health Response on…

40-Year Simulation Results

DeathsAfflictio

n Progress

Affliction Incidence

Vulnerable Reduction

Vulnerable Onset

Percent

Afflicted w/ Complication

(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1

Prev 3 0.5 1 1 1 1

Prev 2+3 0.5 0.5 1 1 1

Prev 1+2+3 0.5 0.5 0.5 1 1

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5

Developing a Scenario-based Research Design

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Putting the System in Motion

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Afflicted with Complications

20,000

10,000

0

0 4 8 12 16 20 24 28 32 36 40Time

Afflicted with Complications : NoRespAfflicted with Complications : Prev3Afflicted with Complications : Prev23Afflicted with Complications : Prev123Afflicted with Complications : Prev123Prot2Afflicted with Complications : Prev123Prot12

Interpreting Behavior Over Time

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DeathsAfflictio

n Progress



Vulnerable Onset

Percent


(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1 11%

Prev 3 0.5 1 1 1 1 14%

Prev 2+3 0.5 0.5 1 1 1 12%

Prev 1+2+3 0.5 0.5 0.5 1 1 11%

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1 10%

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5 9%


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Vulnerable Popn

40,000

32,000

24,000

16,000

8,000

0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time

Vulnerable Popn : NoRespVulnerable Popn : Prev3Vulnerable Popn : Prev23Vulnerable Popn : Prev123Vulnerable Popn : Prev123Prot2Vulnerable Popn : Prev123Prot12


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DeathsAfflictio

n Progress



Vulnerable Onset

Percent


(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1 11% 25%

Prev 3 0.5 1 1 1 1 14% 24%

Prev 2+3 0.5 0.5 1 1 1 12% 24%

Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26%

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1 10% 22%

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5 9% 19%


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Public health response

80

64

48

32

16

0

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40Time

Public health response : NoRespPublic health response : Prev3Public health response : Prev23Public health response : Prev123Public health response : Prev123Prot2Public health response : Prev123Prot12


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DeathsAfflictio

n Progress



Vulnerable Onset

Percent


(T0 = 0%)

Percent Vulnerable

(T0 = 10%)

PH Response

(T0 = 0%)

No Response 1 1 1 1 1 11% 25% 0%

Prev 3 0.5 1 1 1 1 14% 24% 69%

Prev 2+3 0.5 0.5 1 1 1 12% 24% 60%

Prev 1+2+3 0.5 0.5 0.5 1 1 11% 26% 53%

Prev 1+2+3

Prot 20.5 0.5 0.5 2 1 10% 22% 50%

Prev 1+2+3 +

Prot 1+20.5 0.5 0.5 2 0.5 9% 19% 47%


syndemics prevention network the dynamics of upstream and downstream cdc futures health systems...

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