Monograph Menu Report Home Director's Foreword Table of Contents Tables and Figures Acknowledgements Abstract Prologue Introduction Navigating Health Futures Valuing Conditions Crafting Conditions Perceiving Dynamic Conditions Reorienting Public Health Work Transforming Conditions Reflecting on Public. Health. Work. Glossary References About the Author Download Full Report (PDF-8.9Mb)

Perceiving Dynamic Conditions

The Era of Growing Confusion

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In contrast to the era of relative clarity and optimism, the latter half of the 20^th century was a time of growing confusion and complexity. Within living memory, chronic diseases and mental health problems became the leading causes of death and disability. Infectious pathogens evolved vexing capacities of drug resistance. Environmental and occupational exposures took on new proportions in our technologically-dependent, rapidly globalizing economy. And all forms of injury—encompassing things like motor vehicle crashes, suicide, rape, terrorism, warfare, and more—switched from being seen as mere accidents or flaws of human nature into preventable, if still largely perplexing, phenomena (Krug, 2002; Spivak, Prothrow-Stith, Hausman, 1988).

The organizational confusion that now pervades the field shows little sign of stopping. It challenges our thinking and action with at least three significant forms of general complexity (Kahane, 2004; Senge, 2003). First there is dynamic complexity, where the distance between cause and effect is delayed, making causal relationships murkier and more difficult to perceive using conventional analytic methods (Richmond and Peterson, 1997; Sterman, 2000, 2006).²¹ There is also social complexity in the form of plural stakeholders with differing and often conflicting interests (Lasker and Weiss, 2003). This is an important source of variation and challenge that regrettably tends to be obscured by rhetoric emphasizing only the collaborative aspects of public health ventures.²² And a third class of complications stems from the process of adaptation itself, where previously effective solutions have trouble keeping pace with the problems they once solved so well. As Abraham Lincoln put it, “the dogmas of the quiet past are inadequate for the stormy present. Our present is piled high with difficulties, and we must rise with the occasion. As our case is new, so we must think anew and act anew” (Lincoln, 1862).

Beyond these general forms of organizational complexity, which are not confined to the health system, additional challenges arise from the epidemiologic transitions that have literally redrawn the contours of population health throughout the world (Olshansky and Ault, 1986; Omran, 1971; Rogers and Hackenberg, 1987). Over the centuries, and most rapidly during the last 100 years, many nations moved from contending primarily with the pestilence and famines of antiquity to being beset by new forms of population-wide health threats. Researchers have parsed these epidemiologic transitions into four relatively well-documented stages: the age of pestilence and famine; the age of receding pandemics; the age of degenerative and man-made disease; and the age of delayed degenerative disease (Olshansky and Ault, 1986). Each of these epochs is named for the particular type of health problem afflicting the most people and creating the greatest burden within a given nation or region. If we were to look instead at the entire constellation of health threats and how they interact, however, we would likely recognize another, more enduring pattern: the persistence of entrenched syndemics.

The technological and social changes associated with modernity—including the sophisticated actions of public health workers themselves—dramatically altered the types of risks that populations face, shifting the major causes of death and disease from communicable diseases (such as gastroenteric and respiratory infections) to non-communicable diseases, mental health ailments, and various forms of intentional and unintentional injury (Murray, Lopez, Harvard School of Public Health., et.al., 1996). But despite these shifts in absolute burden, all forms of affliction—with the possible exception of smallpox—continue to take their toll even at low levels of incidence. The practical implication for society is clear: we need health protection strategies that address unique problems uniquely, as well as complementary strategies that focus on assuring safer, healthier living conditions for all. Either without the other is likely to fall short of the challenges that we must now confront.

There is also a complicated interplay between disease-causing pathogens and the interventions that we rely upon to prevent and control them. Although still poorly understood, it is now clear that this dynamic sometimes results in the evolution of greater microbial resistance and/or virulence (Ewald, 1993, 1998) . Moreover, age-old afflictions newly understood to be disease-driven (such as alcoholism, substance abuse, depression, and suicide), as well as newly discovered ones (like AIDS, SARS, West Nile virus, and dozens of others in the last 30 years alone) combine to create a broader, more intricate constellation of health threats than was the case in earlier eras. Even the powerful “agent-host-environment” analytic orientation begins to break down in circumstances where so many threats are operating simultaneously.

Responding to wave after wave of these vexing challenges, public health leaders sought innovation by turning to other academic perspectives. Scholars making important contributions came from fields such as anthropology, communications, economics, ecology, ethics, evaluation, history, organizational development, law, philosophy, political science, public policy, psychology, urban planning, sociology, and others. These rich traditions complemented conventional epidemiology in crucial ways, but their incorporation tended to be piecemeal and multidisciplinary rather than integrated and transdisciplinary (Higginbotham, Albrecht, Connor, 2001; Kline, 1995; Rosenfield, 1992). The consequence has been even greater specialization—this time by academic discipline. The boundary of thought and analysis expanded, adding greater texture to the overall health protection enterprise, while exacerbating its underlying problem of fragmentation.

Shifts in causal thinking also moved the field in even more profound ways (Susser, 1973, 1991, 2001). To the ancient and still-popular idea that sickness is a sign of God’s will came new propositions and new evidence about what causes population health problems (Figure 4).²³ Long before the first public health agencies were formed, people saw illness emanating from imbalances in humors, miasma, ether, and other environmental conditions (Ackerknecht, 1948). For instance, an early precursor—though not identical—to our modern notion of a syndemic was Thomas Sydenham’s 17^th century idea of an “epidemic constitution,” in which the temporal pattern of co-occurring epidemics was thought to come from a particular configuration of atmospheric conditions.²⁴

Figure 4: Changing and Accumulating Ideas about the Causes of Population Health Problems

Major parts of Sydenham’s theory were erroneous, but his concepts were “destined to play an important part in the advancement of public health in the nineteenth century” (Rosen, 1993:81). For it was then that Edwin Chadwick and others, believing that unsanitary conditions led to a host of interrelated diseases, would lead Western society in reforming the physical and social conditions of industrial workers as well as the urban poor (Duffy, 1990; Sedgwick, 1902).

Then, toward the turn of the 20^th century, researchers like Henle, Koch, and Pasteur ushered in the germ theory of disease (Evans, 1993; Henle, 1938). Their achievements apparently ended a centuries-long debate about the causal role of specific contagions leading to specific diseases, and it pointed the way toward effective interventions that brought about the first major epidemiologic transition in history. With chronic illnesses like heart disease and cancer on the rise, scholars soon realized that the germ theory’s notion of a single disease tied to a single cause was merely one way of framing causal relationships. They began to recognize that a single disease could have multiple causes (Centers for Disease Control and Prevention, 2003b; Farquhar, 1999); and it was not long before epidemiologists studying risk factors like tobacco reversed this perspective, tying single causes to multiple diseases (Office of the Surgeon General., 2004; Olson, 2004).

Nowadays social epidemiology, with its theory of multicausality linking many causes to many diseases is in vogue (Berkman and Kawachi, 2000; Krieger, 1994, 2001b; Syme and Frohlich, 2002). Its reliance on multi-level modeling (Diez-Roux, 2000), however, represents a very different form of causal thinking compared to the dynamic feedback perspective of a syndemic orientation (Homer and Milstein, 2003a; Milstein, 2002d, 2004c; Richardson, 1991). Whereas multi-level models are correlational and parse variance among parameters chosen from two or more theoretical levels (e.g., individuals and neighborhoods), dynamic feedback models allow analysts to develop and test hypotheses about closed-loop causal relationships. For example, the last bullet in Figure 4 suggests that one might examine the mutually reinforcing causal feedback among afflictions, living conditions, and public strength. A syndemic point of view therefore continues a rapid evolution—and accumulation—of theories about what causes population health problems. For the most part, however, all of these ideas remain alive in the public mind and in the professional literature.

This expansion of the conceptual landscape along with the widening portfolio of risks and diseases demanding some kind of comprehensive response has now stretched the mandates of the public health enterprise so far that even its leaders and teachers cannot succinctly describe it. Susan Scrimshaw, Dean of the School of Public Health at the University of Illinois at Chicago, has offered a magnum of champagne to any of her fellow deans who comes up with a one-sentence description of public health. So far, no one has claimed the prize (Bunk, 2002).

Today, perhaps the most prominent part of the public health landscape in the U.S. is the health care delivery system: an industry in its own right and now the largest sector of the U.S. economy, employing more people than any other, and accounting for 14.9% of the gross domestic product—estimated to reach to 18.4% by 2013 (Heffler, Smith, Keehan, et.al., 2004). Unfortunately, the ways that health agencies are responding to the increasing complexity that they face is, in many cases, adding further complications (Hirsch, Homer, McDonnell, et.al., 2005). Bureaucracies are proliferating, springing up to support categorical funding for separate programs that have great difficulty coordinating their efforts and are defended by advocacy groups representing single diseases, risk factors, or bodily organs. Back in 1988, the immense, unwieldy enterprise was officially declared to be a system in “disarray” (Institute of Medicine, 1988), and that diagnosis remains largely true today.

Almost two decades after that famous declaration, disarray still persists within and among organizations who must now contend not only with direct threats to the public’s health but also with the system-wide organizational problems known as the “diseases of disarray” (i.e. hardening of the categories, tension headache between prevention and treatment, hypocommitment to training, cultural incompetence, political phobia, and output obsession) (Chambers, 1992; Wiesner, 1993). In addition, there are justifiable concerns about widening health disparities and the absence of strong leaders fuels a pervasive feeling of disorientation throughout the field. Worst of all, these three dilemmas—disarray, disparity, and disorientation—are themselves mutually reinforcing: they form a vicious cycle that threatens to undo progress of the past and expose people to preventable suffering at a time when old and new forms of affliction are becoming ever more daunting.²⁵

The deficiencies of the health system and its record of lurching one-step-forward, two-steps-back have been criticized and lamented, but not without sympathy. As the authors of The Future of Public Health marveled, “the wonder is not that American public health has problems, but that so much has been done so well, and with so little” (Institute of Medicine, 1988:2). Much the same can also be said of public health efforts in nations around the globe.

Still, the fact remains that many important achievements of the past look exceedingly fragile today. The eradication of smallpox, a scourge for centuries, is rightly hailed as one of humanity’s greatest triumphs (Fenner, 1988; Fielding, 1999; Foege, 1998). But even this treasured gain is vulnerable today because of the possibility of a malevolent unleashing of this dreaded disease from stockpiles originally held by former Cold War adversaries. In fact, the success of smallpox vaccinations around the world, and their suspension once the disease was eradicated, is a major factor in the degree of our current vulnerability. It highlights the pernicious legacy and the meager progress that we have made in eliminating the preventable causes of war, terrorism, and violent conflict (Bondurant, 1988; Levy and Sidel, 2000; Sharp, 2003; Sidel and Levy, 2003).

Tuberculosis, to take another example, is only one of many diseases that, instead of succumbing permanently to the power of drugs, mutates into drug-resistant strains. Sometimes, burden is not reduced so much as shifted. For example, progress in tobacco control in the United States has accelerated the sale and consumption of tobacco products in developing countries. And iatrogenic disease (i.e., afflictions caused by efforts to heal) take an enormous toll: 98,000 deaths in any given year from medical errors in hospitals alone (Kohn, Corrigan, Donaldson, 2000; Wachter and Shojania, 2004). According to the historian Robert Hudson, “iatrogenic diseases now constitute a significant portion of the total morbidity in industrialized nations; their descriptions fill a book of some 500 pages aptly titled Diseases of Medical Progress” (Hudson, 1983:6).
 

21. The speed of physical and cultural evolution in modern times has yielded a world that is significantly different from the one in which our early ancestors faced, and in which most experimental methods were developed to understand. We have therefore inherited several framing assumptions which prove problematic in under contemporary conditions. “In place of the assumptions of independence, one-way causality, and impacts that are instantaneous and linear, we need assumptions that celebrate interdependence, closed-loop causality, delays, and non-linearities. Only when the representations in our mental models commonly bear these characteristics, will we increase the likelihood that the initiatives we design will create the outcomes we intend” (Richmond and Peterson, 1997:11).

22. The emphasis on collaboration stems, in part, from the situation observed by Joan Bondurant (discussed above on page 25) that social and political theory, including public health science, have “neglected the central question of means, and, therefore, the problem of inevitable conflict” (Bondurant, 1988:v.).

23. This brief history of causal theory was developed with the help of Joel Nitzkin.

24. Sydenham suggested that diseases like plague, smallpox, and dysentery were linked to certain conditions. Whereas under different conditions, a different cluster of epidemics would manifest. Scarlet fever, quinsy, pleurisy and rheumatism, for example, were grouped because they all were thought to depend upon a certain kind of susceptibility in the human body.

25. Disarray and disorientation are related states with different origins and implications. Disarray is an organizational phenomenon, implying the need to rearrange existing parts of a system to improve its performance (usually in the short-term). Disorientation, by contrast, is a conceptual and moral phenomenon, borne of confusion about one’s overall direction, place, and value in the world. Prolonged disorientation may lead to organizational disarray as misguided decisions result in poorly planned or fragmented structures. Conversely, prolonged disarray may lead to disorientation as frustration builds over an inability to effectively reach long-term goals. Also, repeated attempts to reorganize problems that are in fact rooted in disorientation may generate even deeper disarray. In such circumstances, no amount of rearranging will improve long-term performance and the very act of reorganizing could itself become disorienting. Effective responses to disorientation generally require new ways of thinking, framing problems, making decisions, planning, evaluating, organizing resources, and navigating change.

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Page last reviewed: January 30, 2008
Page last modified: January 30, 2008

Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion