Complex public health problems and syndemics : how can these theories guide our practice ?

PHPC CPD event, May 24th 2015Vancouver

Odette Laplante, MD, MSc, CSPQ, FRCPC Médecin conseil, CISSS Chaudière-Appalaches

Yv Bonnier-Viger, MD, MSc, MM, CSPQ, FRCPCDirecteur, DMSP, U Laval

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

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 challengesCompetencies 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

PRESENTATION PLAN

• Introduction• Syndemics• Complex issues and systems dynamics• Lessons for PH practice• Questions for group discussion• Plenary and conclusion

INTRODUCTION

We know :

• multi causality of avoidable disease and injury

• each factor influences several problemsintegrated approaches are more effective

• public health problems are often complex,woven in with social, economic, political issues

• so other sectors share same problems and determinantsHow do we weave these concepts into our strategies?

On what scientific basis ?

SYNDEMICS

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

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

Adapted from : https://onlinecourses.science.psu.edu/stat507/print/book/export/html/25

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

COMPLEX(SOMETIMES WICKED) ISSUES AND SYSTEMS

DYNAMICS

CERTAINTY-AGREEMENT DIAGRAM

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

Adapted from Brenda Zimmerman

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

Adapted from Brenda Zimmerman

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

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

recognitionAdapted from Brenda ZimmermanDRSPCA - DMSPUL - Yv

BIRDS IN FLIGHT FOLLOW 3 SIMPLE RULES

http://gestion-des-risques-interculturels.com/wp-content/uploads/2013/03/nuees-oiseaux.jpg

Separation : avoid touching their neighbourAlignment : follow their neighbour’s directionCohesion : position themselves among their neighbours

HOW CAN WE APPLY THESE PRINCIPLES TO PUBLIC HEALTH

PRACTICE ?

THE NORTH KARELIA CVD EPIDEMIC

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

TOOLS TO DIAGNOSE A COMPLEX OR SYNDEMIC ISSUE

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

JW Forrester, Systems Dynamics and the Lessons of 35 years, chapter 7 in : The systemic Basis of Policy Making in the 1990s, 1991

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. 9http://www.cdc.gov/syndemics/monograph/index.htm

EXPANDING BOUNDARIES OF PUBLIC HEALTH SCIENCE

Source : Milstein, Hygeias constellation, 2008

BUILD A CAUSAL LOOP DIAGRAM

Source : CDC, Syndemics prevention network, Neighborhood Transformation Game: Making the Most of Temporary Assistance, 2006http://www.cdc.gov/syndemics

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

EXPANDING BOUNDARIES OF PUBLIC HEALTH SCIENCE

Source : Milstein, Hygeias constellation

TOOLS TO MANAGE AND IMPLEMENT IN A COMPLEX CONTEXT

« 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

ADAPT ACTION TO THE CONTEXT : THE CYNEFIN FRAMEWORK

Source : Snowden, Boone 2007 (HBR), p. 72

Ordered context• Fact based management• Cause and effect relationships are

perceptible• Simple : best practices• Complicated : expertise (analyse)

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

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 ! ”

ADAPT APPROACH TO THE CONTEXT

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 ?

MANAGING COMPLEX ISSUES

• Dialogues from 3 spheres of scholarship:

public health, systems thinking and modeling, and social navigation

• Develop a common understanding of the problemUsing qualitative and quantitative sources and skills

• Define a common vision and actionsBased on principles of democracy, empowerment and innovation

• Adapt services and empower multipronged changes

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.

REFERENCES

• Complexity science, The challenge of complexity in health care, Paul E Plsek, Trisha Greenhalgh. BMJ, vol 323, 2001-9-15, pp. 625-8

• Complexity science, Complexity and clinical care, Tim Wilson, Tim Holt, BMJ, vol 323, 2001-9-22, pp. 685-8

• Complexity science, Complexity, leadership, and management in healthcare organisations, Paul E Plsek, Tim Wilson, BMJ, vol 323, 2001-9-29, pp. 746-9

• Complexity science, Coping with complexity: educating for capability. Sarah W Fraser, Trisha Greenhalgh, BMJ, vol 323, 2001-10-6, pp. 799-803

REFERENCES ON SYNDEMICS

Introduction to Syndemics: A Critical Systems Approach to Public and Community Health, Merrill Singer, Wiley ed., 2009

Milstein B., Hygeia’s Constellation, CDC, Atlanta, 2008

REFERENCES

38DRSPCA - DMSPUL - Yv

REFERENCES

How Complexity Scienceis Transforming HealthcareBrenda Zimmermanpp. 617-635

REFERENCES

Brenda Zimmerman http://sig.uwaterloo.ca/feature/wici-seminar-applications-of-complexity-science-to-healthcare-brenda-zimmerman

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 2007. 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 – 76https://www.mentalhealthcommission.ca/English/system/files/private/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 http://link.springer.com/chapter/10.1007/978-1-4615-3226-2_7#page-1

• Matta, Nadim F and Ashkenas, Ronald N., Why good projects fail anyway, Harvard Business Review, Sept 2003, https://hbr.org/2003/09/why-good-projects-fail-anyway

MERCI !