Reorienting Public Health WorkSeeing Health Protection as a Whole System
Perhaps the most pervasive image used to describe the essence of public health work is that of a river filled with people flowing toward a dangerous waterfall. Unable to get out of the current, the people cannot save themselves and so their fate rests with those of us on shore, those who see the problem and are moved to respond. How we act, in turn, depends on what we see, how we think, and what we regard as plausible responses.28 It is from this simple caricature that we inherit the language of upstream and downstream effort, first popularized by John McKinlay in the late 1970s (McKinlay, 1979), as well as our most basic notions about the effects of each (Gutman and Clayton, 1999; Mayer, Brown, Linder, 2002; McKinlay and Marceau, 2000c; Richter and Laster, 2004; The Lancet, 1994). Observers standing downstream, below the waterfall, see an urgent crisis of tragic proportions. They search frantically to find anyone who somehow survived the drop amidst the many who inevitably drowned; and when they locate someone who can still be saved, they dive heroically into the churning, deadly waters in an all-out effort to bring them ashore. Theirs is instinctive, immediate, self-sacrificing work, requiring outbursts of tremendous skill, energy, and technological prowess (Kidder, 2004). These helpers quickly tire, yet the flow of people over the waterfall continues, so they call forcefully for others to help in their arduous, but life-saving work. Soon, the downstream river banks team with rescue workers and equipment in support of a crisis that they are unable to stop. Immersed in the frenzy of dragging drowning people from the water, those who work downstream feel that they have no time to think about what is happening upstream—nor the wherewithal to do much about it anyway. They regard the scene before their eyes as the place where all the action is—and the tremendous gratitude of the people whose lives they save each day solidifies that view. Upstream, on the shore above the waterfall, most observers do not notice any problem at all; and the ones that do, perceive it as having very different dimensions. Unable to see exactly what is happening below, they are not aware of the catastrophe unfolding. Some hear the calls for assistance and rush to help with the rescue effort. Others see only swimmers in flat water without thinking about the danger ahead. Even the swimmers themselves may not understand the full scope of their predicament. But certain observers—those who know the terrain best, who appreciate how powerful the current is and where it goes—recognize the need for immediate action. Animated by the foresight of an impending tragedy, they begin alerting people to the danger ahead and extending lifelines to encourage their peers safely ashore. Skeptics, both in the water and on land, may resent or resist this flurry of effort in the face of an invisible problem. But still, an ambitious enterprise develops to help people out of the river, all in the name of prevention. News of the crisis eventually travels even farther upstream. First to people on the bridge, who set out to repair the hole where most of the swimmers fell through. And then to engineers at the dam, who manage to close the broken flood gate and dry up the river itself. Despite being so contrived, this parable of public health work is told and retold in schools of public health throughout the world. It illustrates the natural, humane tendency to care for those who fall ill as well as the profound inadequacy of relying solely on those last minute services. More importantly, it reveals practical opportunities to avert tragedy long before the worst occurs; and it underscores what Bill Foege, former CDC Director and now senior strategist for the Gates Foundation, famously observed: “public health thinkers see into the future, for they understand that it is the first cigarette that kills and not the last” (Foege, 2000). If the river symbolizes the dynamic flow of time across the lifespan (or across generations), then the many actors along its shore—both upstream and down—represent the enormous cast of characters who are in a position to help safeguard the public’s health—before, during and after adversity sets in. Upstream action tends to be held as the ideal of public health work and its relative infrequency is rightfully criticized as the chief failing of our society. But in the macroscopic view that a syndemic orientation offers, we see not just the need for vigorous upstream effort, but rather the imperative to organize a balanced system of health protection: one that orchestrates as seamlessly as possible a variety of simultaneous efforts to safeguard people’s health (Jackson, Valdesseri, CDC Health Systems Work Group, 2004). Figure 10, developed in collaboration with system dynamics expert Jack Homer, presents a sketch of what such a system might include (Milstein and Homer, 2003).29 The four boxes represent different states of health that people in a population could enter. Think of them as bathtubs, each with a different level of water (or prevalence of people) (Booth-Sweeney and Sterman, 2000). These groups range from a population of safer, healthier people to those whose complicated afflictions put them on the verge of premature death. The double arrows indicate transitions between one health state and another with valves controlling the rate of flow (or the speed at which people move). Susan Sontag captured this same fluid character of population health when she spoke in more dichotomous terms of us all having “dual citizenship” among the well and the sick. Figure 10: A Balanced System of Health Protection
Movement between these kingdoms—and how long our “spells” in each state last—is influenced to varying degrees by our genetic inheritance; exposures to environmental conditions at home, work, play and elsewhere; individual behaviors in response to those environments (or in spite of them); social networks; income; education; receipt of health care services; and thousands of other factors. Moreover, any one of these factors may influence and be influenced by the others, forming a massively entangled feedback dynamic that drives movement throughout the system.30 As the waterfall parable illustrates, our organized responses to the flow of population health—irrespective of how strong the current is or how well we understand its dynamics below the surface—have the potential to govern how the future unfolds. Decisions about how far up and downstream we work literally affect who lives, who dies, who bears the burdens of vulnerability and affliction, and how hard we must all work in the process. Each distinct type of response, however, requires that different actors engage in different kinds of effort with very different effects. It is these dynamics of the overall health protection system that Figure 10 attempts to formalize. As the number of people with afflictions and complications rises, the demand for some kind of societal response builds. Initially, that response might be concentrated entirely downstream in an effort to slow the rate at which people are dying prematurely (tertiary prevention). Regardless of how successful that work is, its limited impact—signaled by the continued growth of people with afflictions and complications—eventually prompts a complementary effort to reduce the rate at which people are developing complications (secondary prevention). By that same logic, the response portfolio expands still further to include efforts to limit the number of people who are becoming afflicted in the first place (primary prevention). Most formal teaching, research, and policy analysis tends to focus on one or more of these three responses: primary, secondary, and tertiary prevention.31 The best that we can do, one may conclude from mainstream authors, is prevent people at risk from becoming sick, suffering complications, and dying prematurely. But even a rudimentary system analysis suggests that there is more to the story. Over the past four decades, as ecological and systems thinking have reshaped our collective consciousness (Green, Richard, Potvin, 1996; McLeroy, Bibeau, Steckler, et.al., 1988; Stokols, 1996), it has become increasingly clear that we need not accept health risks at face value. Instead, we may “question the givens” by examining and ultimately transforming the myriad ways in which human societies configure and distribute vulnerability differentially through our public and private choices . This line of inquiry joins health science with a vast history of ideas about power, how it is used, and how it affects both people and the world in which we live (Berlin, 1996; Zinn, 1999). Even before turning to the formidable task of developing theories about the social production of risks and diseases (Krieger and Zierler, 1996), there are practical steps that we can take to complete our map of the health system. Returning to Figure 10, we may look still farther upstream, beyond primary prevention, by recognizing that those who become afflicted come from a group who are vulnerable to the risks for one or more types of disease, injury, or disability.32 Likewise, the population of vulnerable people comes from those who are safer and healthier, through a process of becoming vulnerable to adverse living conditions that—for whatever reason—they are unable to avoid. Placing these population groups on the map reveals two additional types of health response: targeted protection and general protection. As the figure indicates, public work powers the overall societal response, but each of the five particular response types has a different structural property in that each affects a different rate of flow. The three downstream actions are labeled prevention because they work to prevent or slow the progression from an undesirable health state to one that is even worse. By contrast, the two upstream actions are protective in that they seek to help people move away from positions of vulnerability (targeted protection), or eliminate the adverse conditions that threaten people’s health and loom so large as culprits in the forced migrations from the kingdom of the well to the kingdom of the sick (general protection). The capacity to perform public work in any of these modes, however, rests on the degree of public strength, which itself is undermined by the processes of social division or enriched through social equity. Unlike material resources, such as money or technology, public strength builds with its use as citizens enter and become involved as actors in governing public life (Boyte, 2004b). In 2004, CDC Director Julie Gerberding announced that, “we are redefining CDC as the nation’s health-protection agency” (Park, 2004). With that, she signaled an interest in expanding the organization’s scope of concern beyond what had been implied by the previous moniker: the nation’s prevention agency.33 In a nationwide satellite broadcast intended to articulate the rationale for this shift in strategy, Gerberding used a simplified version of the graphic in Figure 10 to explain the profound imbalance in downstream vs. upstream effort, as well as CDC’s commitment to help correct the problem.
To move in this direction requires far different strategies and tactics, as well as contributions from new and more diverse sets of actors. It requires a better balance between two areas of emphasis that even today are often pitted against one another, viewed with mutual acrimony, or simply seen as worlds apart (Figure 11). Figure 11: Balancing Two Areas of Emphasis The effective management of risks and diseases is a world of providers providing. They offer a wide range of services, information, and support intended to help people in need: health education, screening, medical monitoring, pharmaceuticals, clinical services, physical and financial access to care. But no matter how well or how extensively they provide these things, the waves of vulnerable and afflicted people may keep coming because, structurally speaking, such services are virtually powerless to affect those upstream flows. Transforming the conditions that leave people vulnerable to the large constellation of modern afflictions is a tall order (and a partial explanation of why it happens so rarely). Many of the most adverse living conditions—like severe deprivation, dependency, violence, discrimination, environmental decay, stress, and insecurity—have been entrenched within certain subgroups for decades or centuries. Changing them requires strengthening leaders and institutions and moving fearlessly towards the practice of democratic pluralism: that is, a system of governance wherein all citizens not only coexist but thrive. It requires shifting power relationships that, not coincidentally, are just as entrenched as the adverse conditions themselves. This is the world of intense public organizing, day-to-day work by citizens to shape a commonwealth that upholds their values. It demands self-governance by means of politics in the nonpartisan sense of powerful, creative engagement in public life (Boyte, 2004b; Crick, 1993). It is a world that many public health professionals and institutions have shied away from toward the end of the 20th century, to the approval of some and the dismay of others (Baum and Sanders, 1995). As uncomfortable as this nonpartisan but politically-engaged emphasis can be for those who would separate epidemiology from action (Atwood, Colditz, Kawachi, 1997, p.1604; Rothman and Poole, 1985), it seems no longer optional (if ever it were).34 One of the truths that public health assessments have documented over the years is that the distributions of vulnerability and affliction do not occur randomly in human populations (Antonovsky, 1967). Across the globe, the heaviest burdens fall upon those who are socially marginalized, disenfranchised, or oppressed, whether they live in North Dakota or North Korea (People's Health Movement, 2004; World Health Organization, 2004b). Even new forms of affliction, as was the case with HIV/AIDS, quickly gravitate to take hold among minorities (Mann, Tarantola, Netter, 1992). This concentrates disease among disadvantaged groups, who then become even more vulnerable as health threats reinforce one another in a vicious cycle.
Equipped with scientific knowledge about disease causation, health professionals have been quick to predict how the future may unfold. But in the past three to four decades many health agencies—and the staff who lead them—have become relatively reluctant to enter the public arena where navigational choices are made.35 Strong traditions in the field favor anticipating the future, instead of actively governing it (Bambra, Fox, Scott-Samuel, 2003, 2005). Those who operate from a syndemic orientation challenge that stance by expanding the boundaries of scientific thought and action in at least four directions (Figure 12). Figure 12: Expanding Boundaries of Public Health Science
If ours is an era of enlarging imagination, then it has become so because innovators, in increasing numbers, are
It is possible to observe recent innovations pressing in all four of these directions—not often simultaneously in any one instance, but collectively across the field. In dozens of daily examples, health workers pursue these imaginative directions in new ways and with new intensity, aided by an array of ever-changing conceptual and methodological tools. The outward lines in Figure 12 highlight just a few of these tools—ecological thinking, causal mapping, simulation modeling, and democratic public work—which are indicative of whole classes of similar methods that support a syndemic orientation.36 They also stand for techniques that have yet to be devised, but most likely will be in the years ahead as we come to appreciate the significance and pragmatic importance of enlarging our work along these dimensions. The next section provides a glimpse into how these illustrative methods alter public health thinking and thereby open new possibilities for transforming both the world and the health of people in it. Relational or ecological thinking situates people in places, revealing a world of interdependent systems from the local to the global. This reinforces the inherent interconnection among people and among places, providing a mandate for working toward global health equity. The North Karelia Project in Finland, described in the following section, exemplifies how the citizens of a large region and later of an entire nation used insights about their local economy, culture, and values to radically alter their own health futures. Causal mapping is a technique to examine the structural dynamics that govern health problems. By creating and analyzing these maps, it may be possible to identify certain high-leverage drivers with system-wide influence, and thereby simplify the operational objectives for health action even while aligning the efforts of more diverse stakeholders. One of the many virtues of causal mapping is that it allows surprising or counterintuitive insights to surface and be better explained, as was the case in an analysis (summarized below) on the timing and sequence of outside assistance in neighborhoods challenged by multiple epidemics. A closely related technique, simulation modeling, puts causal maps in motion, compressing decades into seconds, and allowing analysts to play out long-term scenarios of various policy options. This tool helps planners better understand the connection between structure and behavior in our dynamically complex world by providing a way to explore a wide set of plausible futures. It also gives policy makers the opportunity to assemble broader support for a desired course of change, and to rehearse how they may handle periods of declining performance. In the example below, simulation modeling is used to study a particularly vexing syndemic: diabetes in the era of accelerating obesity. Finally, democratic public work builds the public strength that is needed in an open society for all citizens to have the freedom to protect themselves and to participate in navigating the course of change. Unleashing the energy of youth, as described below, is one inspiring and far-sighted way of changing individuals and societies for generations to come. Another is to consciously change the culture and organizational character of public institutions, as the CDC is now undertaking with its Futures Initiative (Centers for Disease Control and Prevention, 2004d). Each of these examples provides a glimpse into the transformations that are so central to the further flourishing of a syndemic orientation.
29. A more complete dynamic hypothesis is presented in (Milstein and Homer, 2003). 30. Gross effects of the health system’s behavior can be observed by tracking changes over time in the fraction of the total population in each of these four health states. If used in this way, the population stock-and-flow structure provides a dynamic accounting system for assessing progress toward the goal of enlarging the number of people in the safer and healthier state, or least maximizing the time they stay outside of the more downstream states, perhaps measured as the cumulative number of person-years spent in each. 31. A notable exception is the concept of “primordial prevention,” which seeks to prevent future disease by influencing its social determinants. This evocative label was coined by Henry Blackburn in 1982 and is still commonly discussed among scholars of cardiovascular disease (DeBusk, 1999; Farquhar, 1999; James, 1999; Watkins, 1984). 32. Most studies indicate that populations with one risk factor are far less common than those with multiple risk factors (Atkins and Clancy, 2004; Hahn, Vesely, Chang, 2000). This adds further support to the syndemic view that vulnerable populations are prone to several forms of interacting afflictions. 33. The words “and prevention” were added to CDC’s name–but not its acronym–in 1992 to underscore a renewed emphasis on preventive action. The idea of protection, by contrast, has taken on added significance in this era of war and bioterrorist threats. But even before these most recent events, the idea of protecting the public from various types of harm and vulnerability has been a strong force in public health thinking, all the way back to figures like Hygeia in Greek mythology and her counterparts in other systems of belief. Although the term protection is not used as often as prevention among health professionals, outside the profession–with members of the public–it seems to have greater resonance, conjuring reassuring notions of safety, watchfulness, and active caring (Kirby, Taylor, Freimuth, et.al., 2001). Even without the name, the public may regard CDC as working in this protective mode, which could account as part of the reason why Americans rate CDC highest among all federal agencies in annual opinion polls (Associated Press, 2004). 34. There are, of course, some instances in which even nonpartisan political practices are prohibited, such as Congressional lobbying by federal employees. 35. Efforts to reduce tobacco consumption are a notable–and successful–exception. Efforts to limit gun violence are another exception, albeit with less measurable success to date. 36. Other intriguing approaches could have also been highlighted, such as network analysis (Scott, 2000; Wasserman and Faust, 1994), agent-based modeling (Rahmandad and Sterman, 2005), complex adaptive systems (Olson and Eoyang, 2001; Tan, Wen, Awad, 2005), human systems dynamics (Eoyang, 2003; Eoyang, 2001; Human Systems Dynamics Institute, 2003), appreciative inquiry (Cooperrider, Sorensen, Whitney, et.al., 2000), health impact assessment (Davenport, Mathers, Parry, 2006; Quigley, Keville, Taylor, 2005; World Health Organization, 2005b), summary measures of population health (Murray, Lopez, Salomon, et.al., 2002; Veerman, Barendregt, Mackenbach, 2005), geographic information systems (Ong, Graham, Houston, 2006), storytelling (Kibel, 1999), journey mapping (Kibel, 2001), power and interest mapping (Hildreth, 1998), futuring (Bezold and Hancock, 1993; Garrett, 1999), guided evolution (Banathy, 2000), large group methods for enhancing democratic participation, and many more.
Page last reviewed: January 30, 2008 Content source: Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion |
