Exploring Interfaces Between Public Health and Democracy

1
Exploring Interfaces Between Public Health and
Democracy
Dialogue with Members of the Humphrey Institute
for Public Affairs and the Jane Addams School
for Democracy
Bobby Milstein December 17, 2003
2
Background on the Syndemics Project

• Planned as a three-year study of innovations in
  health planning and evaluation
• The word syndemic signals special concern for
  relationships
• mutually reinforcing character of health problems
• connections between health status and living
  conditions
• synergy/fragmentation within the health system
  (by issues sectors organizations
  professionals and citizens)
• Phase 1 identify innovations and dilemmas
  develop working definitions explore concepts and
  methods
• Phase 2 articulate the foundations of a syndemic
  orientation find creative ways of using this
  perspective to transform public health work at
  the CDC and beyond

3
Seeing a Wider Set of Relationships
4
Innovations Point to the Emergence of a Syndemic
Orientation

• Public health work is becoming more
• Inter-connected (ecological, multi-causal,
  dynamic) Concerned more with leverage than
  control
• Public (broad-based, citizen-led, multi-sector,
  democratic) Concerned with many interests and
  mutual-accountability
• Questioning (evaluative, reflexive,
  practical)Concerned with values like justice,
  worth, significance, and freedom in both means
  and ends

5
A Complementary Science of Relationships

• Efforts to Reduce Population Health
  ProblemsProblem, problem solver, response
• Efforts to Organize a Health System that Protects
  the Publics HealthDynamic interaction among
  multiple problems, problem solvers, and responses

6
The Field of Prevention Science is Expanding
InnovativeHealth Ventures
7
Public Health Began as Public Work
Public death was first recognized as a matter of
civilized concern in the nineteenth century, when
some public health workers decided that untimely
death was a question between men and society, not
between men and God. Infant mortality and
endemic disease became matters of social
responsibility. Since then, and for that reason,
millions of lives have been saved.The pioneers
of public health did not change nature, or men,
but adjusted the active relationship of men to
certain aspects of nature so that the
relationship became one of watchful and healthy
respect.
-- Gil Elliot
Elliot G. Twentieth century book of the dead. New
York, C. Scribner, 1972.
8

• The term epidemic, first used in 1603, signifies
  a kind of relationship wherein something is put
  upon the people
• Epidemiology appeared 270 years later, in the
  title of J.P. Parkin's book "Epidemiology, or the
  Remoter Causes of Epidemic Diseases
• Ever since then, the conditions that cause health
  problems have increasingly become matters of
  public concern and public work

9
A Different View of Causal TheoryWhat accounts
for poor community health?

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

1840
1880
1950
1960
1980
2000
10
Phenomenal Progress
Increasing Longevity United States 1900-1990
Public health achievements of the 20th century
dwarf those accumulated in the previous
19. -- Jeffrey Koplan
Wilmoth JR. The Future of Human Longevity A
Demographer's Perspective. Science
1998280(5362)2.
Koplan J. CDC sets millennium priorities. US
Medicine 19994-7.
11
Top Ten Public Health Achievements in the 20th
Century

• Vaccinations
• Safer, uncontaminated food supply
• Flouridation of drinking water
• Safer workplaces
• Control of infectious diseases (sanitation
  antibiotics)
• Motor vehicle safety
• Healthier mothers and babies
• Safe contraception and family planning
• Decline in deaths from heart disease and stroke
• Recognition of tobacco as a health hazard

CDC. Ten great public health achievements --
United States, 1900-1999. MMWR 199948(12)241-243
.
12
There is Great Power in Focusing on One Problem
at a Time
"Certain forms of knowledge and control require a
narrowing of vision. The great advantage of such
tunnel vision is that it brings into sharp focus
certain limited aspects of an otherwise far more
complex and unwieldy reality. This very
simplification, in turn, makes the phenomenon at
the center of the field of vision more legible
and hence more susceptible to careful measurement
and calculation.making possible a high degree of
schematic knowledge, control, and manipulation."
-- John Scott
Scott JC. Seeing like a state how certain
schemes to improve the human condition have
failed. New Haven London Yale University
Press, 1999.
13
Blood Lead Levels in the U.S. Population 19761999
14
Actual and Expected Death Rates for Coronary
Heart Disease, 19501998
700
Rate if trend continued
600
500
Peak Rate
400
Age-adjusted Death Rate per 100,000 Population
300
200
Actual Rate
100
50
1950
1960
1970
1980
1990
1995
1955
1965
1975
1985
Year
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.
15
Adult Per Capita Cigarette Consumption and Major
Smoking-and-Health EventsUnited States, 1900-1998

1st Surgeon Generals Report
Broadcast Ad Ban
Federal Cigarette Tax Doubles
End of WW II
Nonsmokers Rights Movement Begins
1st Smoking- Cancer Concern
Great Depression
Source USDA 1986 Surgeon General's Report
16
Solutions Can Also Create New Problems

Merton RK. The unanticipated consequences of
purposive social action. American Sociological
Review 19361936894-904. Forrester JW.
Counterintuitive behavior of social systems.
Technology Review 197173(3)53-68.
17
Even the Greatest Gains are Fragile

18
Solving for Pattern
"A bad solution is bad because it acts
destructively upon the larger patterns in which
it is contained...because it is formed in
ignorance or disregard of them. A bad solution
solves for a single purpose or goal, such as
increased production. And it is typical of such
solutions that they achieve stupendous increase
in production at exorbitant biological and social
costsGood solutions recognize that they are part
of a larger whole. They solve more than one
problem and don't create new problems. A good
solution should not enrich one person by the
distress or impoverishment of another."
-- Wendell Berry
Berry W. Solving for pattern. In The Gift of
Good Land. San Francisco North Point 1981. p.
134-45.
19
A Glimpse Into 2020
Murray CJL, Lopez AD. The global burden of
disease summary. Cambridge, MA Harvard
University Press, 1996.
20
A Glimpse Into 2020

• On the Top 15 List
• War
• HIV
• Violence
• Self-inflicted injury
• Cancer of the trachea, bronchus, and lung

• Off the Top 15 List
• Measles
• Malaria
• Falls
• Anemia
• Malnutrition

Murray CJL, Lopez AD. The global burden of
disease summary. Cambridge, MA Harvard
University Press, 1996.
21
SpecializationA Proven Problem Solving Approach

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

• Repeat steps 1-4, as necessary!

22
Side Effects of Specialization

• Confusion, inefficiency, organizational disarray
• Competition for shared resources
• Attention to local causes, near in time and
  space
• Neglected feedback ( and -)
• Confounded evaluations
• Coercive power dynamics
• Priority on a single value, implicitly or
  explicitly devaluing others
• Limited mandate to address context (living
  conditions) or infrastructure (public strength)
• Disappointing track record, especially with
  regard to inequalities

Neighborhood
23
Dangers of Getting Too Specific

• Conventional problem solving proliferates
  problems
• Opens a self-reinforcing niche for professional
  problem solvers
• Obscures patterns that transcend any specific
  problem

Krug EG, World Health Organization. World report
on violence and health. Geneva World Health
Organization, 2002.
24
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.
25
The picture looks different if we think about
peoples overall state of health or affliction
14 increase
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 lthttp//apps.nccd.cdc.gov/HRQ
OL/gt.
26
Is there some way to get a larger, more dynamic
overview of the whole health system without
loosing sight of unique disease processes
involved?
27
Public Health Goals Are Expandingand
Accumulating
The perfection of means and confusion of goals
characterizes our age. -- Albert Einstein

• Prevent disease and injury (1850 -- present)
• Promote health and human development (1974 --
  present)
• Assure the conditions in which people can be
  healthy (1988 -- present)

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Why Do We Do Public Health Work?
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 societys 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.
29
What does it mean to organize science and society
around the goal of assuring healthful conditions?
30
Basic Dynamics in the Health System
From 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
Workgroup Atlanta, GA 2003.
31
Preliminary Dynamic Hypothesis Work in Progress
32
Health System Dynamics
33
Health System Dynamics
34
Health System Dynamics
35
Health System Dynamics
36
Health System Dynamics
37
Health System Dynamics
38
Health System Dynamics
39
Health System Dynamics
Downstream lock-in Delay in upstream effort
guarantees continued growth in affliction
prevalence and emphasis on treatment, which
further delays upstream effort, as does mounting
social disparity.
40
Health System Dynamics
Full map, with contagion and diffusion loops
41
Many Health Professionals Do Not See Themselves
as Part of the Public
The challenge of involving the community is
especially difficult if one has been trained, as
I have been trained, to be an arrogant, elitist
prima donna. I am the "expert," after all, and I
help people by sharing my expertise.
-- Len Syme
Syme SL. Social determinants of health the
community as an empowered partner. Preventing
Chronic Disease 2004 1(1) Accessed December 15,
2003. Available from http//www.cdc.gov/pcd/issu
es/2004/jan/syme.htm
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Areas of Emphasis
43
Dependence on Living Conditions
"Each of us has an array of basic needs that
must, by and large, be satisfied continuously. We
cannot, for instance, do for very long without
fresh water, or waste elimination, or sleep.
Accordingly, each of usindividually and
collectivelyrequires a synergistic package' of
resources and suitable environmental conditions.
A society that can reliably provide this package
will thrive and possibly grow larger. But if
even one of these needs is not satisfiedif any
part of the package is deficientthe entire
enterprise is likely to be threatened"
Corning PA. Presidential speech the systems
sciences in the year 3000. International Society
of the Systems Sciences, 2000. Accessed April 23,
2002 at lthttp//www.complexsystems.org/commentarie
s/jul00.htmlgt.
44
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.
45
Prerequisite Conditions for Health
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.
46
Human Development Freedoms

• Health
• Education
• Standard of living
• Political participation
• Social engagement
• Physical security

UNDP Human Development Index
Sen AK. Development as freedom. New York Anchor
books, 1999. United Nations Development
Programme. Human development report 2002
deepening democracy in a fragmented world. New
York Oxford University Press 2002.
47
Seeing Conditions as Freedoms

• Adverse living conditions are circumstances that
  inhibit people's freedom to live and develop
  their full potential.
• They include, at a minimum, any deviation from
  prerequisite conditions for life and human
  dignity (e.g., physical extremes, violence,
  deprivation, disconnection).
• Phenomena like hunger, homelessness, joblessness,
  illiteracy, war, environmental decay, and various
  forms of injustice, including racism, are all
  examples of adverse living conditions.

48
Choice and Non-Choice
If we aim to affect health behavior, we have to
examine the circumstance that generate behavior
and understand the relation of choice to
non-choice. Choices are always made from among
alternatives presented by the social environment,
or by circumstances that were themselves not
chosen. Choice depends on the tools for making
choices, the outer edge of people's aspirations
as they have been encouraged or dampened by past
experience. When we recognize the elements of
non-choice in choice, we can escape the
contradiction between social causation and
individual responsibility and understand the
interactiveness of the two.
Levins R, Lopez C. Toward an ecosocial view of
health. International Journal of Health Services
199929(2)261-93.
49
Linking Living Conditions to Peoples Freedoms
Prerequisite Conditions for Health Requires Freedom From
Physical security Physical extremes
Peace Violence
Minimal standard of living Deprivation
Social engagement Disconnection
Stable organic processes Impaired metabolism
Mental/emotional balance Impaired cognition/emotion
Successful reproduction Impaired reproduction
50
Linking Living Conditions to Freedoms
Healthy State Freedom From Selected Examples Selected Examples
Physical security Physical extremes Crash, fire, fall Heat, cold Radiation Hazardous substances Natural disaster Infectious diseases
Peace Violence Homicide Suicide War Rape
Minimal standard of living Deprivation Malnutrition Homelessness Poverty Joblessness Overcrowding Illiteracy Inadequate education
Social engagement Disconnection Inequality Injustice Dependency Incarceration Runaway Neglect
Stable organic processes Impaired metabolism Heart disease Cancer Stroke Diabetes Arthritis Obesity
Mental/emotional balance Impaired cognition or emotion Depression Anxiety Attention deficit Lack of recreation
Successful reproduction Impaired reproduction Infertility Miscarriage Birth defects Infant mortality
51
Creating a Safer Healthier Future
We cannot predict history but we can make it and
we can make evolution. More we cannot avoid
making evolution. Every reform deliberately
instituted in the structure of society changes
both history and the selective forces that affect
evolution though evolutionary change may be the
farthest thing from our minds as reformers. We
are not free to avoid producing evolution we are
only free to close our eyes to what we are doing.
-- Garrett Hardin
52
Seeing Beyond the Probable
Most organizations plan around what is most
likely. In so doing they reinforce what is, even
though they want something very
different. -- Ciement Bezold

• PossibleWhat may happen?
• PlausibleWhat could happen?
• ProbableWhat will likely happen?
• PreferableWhat 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.
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The Essence of Protection
"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
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Pacific Island, Earth Island Survival
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Choosing a Path
"America was not on a road to survival before
Martin Luther King. Atlanta would not look like
the thriving metropolis that it is now. Atlanta
would probably look more like Beirut if history
had gone its normal course, the normal violent
American way."
-- Andrew Young
From Kearns K. In Remembrance of Martin. PBS
Video, 1999.
56
Questions

• What forces separate public health from public
  work? What forces draw the two closer?
• How can professionals see themselves as citizens
  and expand opportunities for public work?
• What are the prospects for reconnecting health
  and work?

57
What Forces Separate Public Health from Public
Work?

• Incentives and rewards linked to research and
  planning and the growth of service delivery
  programs, not transformative action and long-term
  health improvement
• Rise of the health care industry
• Historical division between science and politics
• Commitment to stepwise progress (solving for
  singular values)
• Others.

58
What Forces Draw Public Health Closer to Public
Work?

• Concern for health and health equity
• Focus on assuring conditions in which people can
  be healthy
• Principles/standards for public health ethics
• Emphasis on leadership, partnership, and
  inter-sectoral action
• Methodological innovations (e.g., summary
  measures of health, health impact assessment,
  dynamic simulation modeling)
• Public scrutiny and accountability
• Increasing interdependency among people, places,
  problems
• Others.

59
Remaining Questions

• Science is PoliticalWhy do contemporary health
  professionals and institutions resist
  non-partisan political engagement and democratic
  public work?
• Professionals are CitizensHow can professionals
  overcome their tendency to act like arrogant,
  elitist, prima donna, experts and begin doing
  more public work?
• Public Health requires Public WorkWhat are the
  prospects for reconnecting peoples work with
  health goals?

60
Should Our Capacities for Public Health Work be
Integrated or Divided?
100 Divided
100 Integrated
61
For Additional Information http//www.cdc.gov/synd
emics