2008/07/14 09:20 Bobby Milstein, "Crafting a Health System that Protects Us All"

ISSS Madison 2008, 52nd Annual Meeting of the International Society for the Systems Sciences

This digest was created in real-time during the meeting, based on the speaker's presentation(s) and comments from the audience. The content should not be viewed as an official transcript of the meeting, but only as an interpretation by a single individual. Lapses, grammatical errors, and typing mistakes may not have been corrected. Questions about content should be directed to the originator. The digest has been made available for purposes of scholarship, posted on the ISSS web site by David Ing.

Intro by Gary Metcalf

Bobby Milstein

  • Center for Disease Control, Syndemics
  • Cultural anthropology, science, systems science

Something that matters to all of us:  who lives, who dies, how much money we spend on things

A systems approach to public health science:  if not systems, would be mechanistics

5 questions:

1. What's changing in the world? 

  • Retrospective. 
  • CDC does telephone surveys, of the last 30 days, how healthy have you felt?
  • Over 15 years, it's been down
  • Have lost about a working day per month over the last 15 years
  • This generates passion and anger

2. Presses towards questions:  why?

  • Epidemiology
  • Systems approach can't stop here

3.  Where will this head in the future?

  • Scenarios, could be tomorrow, or transformation changes
  • Want to narrow the envelope of possible futures

4.  How do we get on trajectory?

5.  Who do we need to get onto a trajectory?

  • Opportunity for actors to make a difference

U.S. is in an election year

  • Seeing a consensus that the health system needs to change

Have seen this before

3 approaches

  • Piecemeal approach
  • Complicated schemes that were opposed by special interests
  • Assumptions that healthcare dynamics are separate from other areas of public concern

Policy resistance comes from a narrow view

  • Thus, use a boundary critique
  • The health system is not the health system perceived
  • e.g. lack of health protection causes need for health care
  • e.g. lack of health equity
  • Challenge to align conceptual orientation with a method:  it's not right or wrong, it's a conceptual way of thinking
  • Grounded in studies of innovation, and epidemics
  • Innovators borrow from other fields of practice, redefine vocabulary and language

Syndemic: one health problem predisposes you or makes it easier of you to get another health problem.

  • Health is only one part of life
  • We can have some influence over own health, then how well can we organize upstream?
  • Health states <--> living conditions
  • Impacts health policy, and social policy


  • 19th century people didn't change nature of men, they adjusted the relationships with men
  • Specialization gives benefits, but leads to fragmentation


  • Not just entities, but how things link in the world

Procedures to formalize ways of seeing the world

  • Mostly time series models and multivariates, to get variables
  • Haven't done so much on structural views that would show all new trends, use in a what-if mode


  • Not just diseases, but patterns
  • Communicate with the field

CDC got ASysT award, this year as first

Want to understand how leaders in health service transformation

  • Need to learn in a simpler system, first:  simulation
  • Then, it is too audacious to represent the whole U.S. health system:  yes, it would be like being in the middle of a hurricane, trying to understand what is going on
  • Approach:  narrow to a few discrete policies
  • Start with insurance, but then get beyond that focus on cost on health care delivery

10 policies:

  • Insurance
  • Qualty of care
  • Reimbusement rates
  • Administrative structure
  • Ability of people to quick smoking or exercise
  • Exposure 
  • Subgroups of individuals more advantaged or disadvantaged
  • Building public leadership, so that issues can be tackled effectively

Rendered this as a game:  the Health Protection Game

  • Proritize the 10 policies
  • Scoring system:  
    • save lives
    • improve well being
    • achieve equity
    • lower healthcare spending
    • expenses
  • User's challenge to move it to a better state
  • It's a structured list of health policies

Last week, news on whether we should suppress doctor's reimbursements

  • What does this do in simulation?
  • Cutting reimbursements could increase death rate rather quickly, as cutting reimbursement reduces quality, so people will go to ER
  • More unhealthy days
  • Inequity has improved, and then rebounds later
  • It suppresses costs for 1.5 years, and then worsening health patterns increases overall costs
  • Can then drill down to see why

Looking at universal coverage policies:

  • They improve health
  • In no cases does this result in saving money
  • Almost always erode inequities

Upstream health protection is favourable, but takes 10 to 15 years

Have prototype, developing this

  • Can see what we're getting the results
  • Challenge to position this as a tool for leadership, not create another report presciption that will go on the shelf
  • Polynesian idea of wayfinding
  • They want a plausible pathway

Learning how to transform health systems, not just afflictions or adverse living conditions, but also some efforts to build power where all citizens have a role

  • Changes from a conversation on quality of outcomes to one focused on equality of opportunities, as equality of agency

Difference between syndemic and epidemic view

  • Boundary critique
  • Causal mapping for governing dynamics
  • Dynamic modeling to get plausible futures
  • Democratic public work to get navigation freedoms

More information at http://www.cdc.gov/syndemics


Longer living.  Increasing human biomass?

  • Have not linked to environmental sustainability
  • This deserves more connection
  • We lack the leadership to connect them together
  • Would be delighted to see these types of studies
  • Forrester, World Dynamics, had increasing population
  • In health field, the successes in the past suppress infectious diseases
  • More people living longer with needs for higher health
  • In this country, health care costs can lead to bankrupcy

Israel, public health discourage people, people dying sooner

  • Providing more insurance coverage, versus engaging cost of health
  • Guidelines are currently 50% of recommended to maintain health

Feedback: dynamics between sexes, could reduce population, then would impact education.  Complexities around accountabilities, achieving goal within a subsystem, impacting whole

  • Millenium Impact Assessments have gender equity and other factors
  • Challenge finding people who can think planetary, and then do something within their own organizations
  • Political science that systems scientists may not have harnessed enough

In New Zealand 2007, "Wellbeing and its time to come", our common future, getting people involved in the policy.  Simulation approach dovetails with Australia evidence-based policy, were modeling is based on individuals, enhancing democracy

  • Pitfall of professionalism:  someone better education is better trained
  • Some people think need a Ph.D. just to be confused
  • Need to open up the boundary
  • Other conditions, e.g. transportation, environment
  • Getting a non-partisan view

American living in Canada, part of a survey that asked what provided for good health.  Health care available was the fourth criteria:  Income, lifestyle and occupation higher.  How is it possible, given system dynamics model, looking at income disparities, lifestyle choices, and risks that people take?  Studies of EPA, and how much climate change, spending on making roads safer, bigger picture

  • U.S. PBS aired 4 parts in 7 hours on unnatural causes:  is inequality making us sick?
  • Doctor like taking your car into a garage
  • Pivoting from widespread confusion about are they important to both/and

Allopathic care, disease prevention.  Medicine is focused on the organism down.  Traditional medicine looks at health, well-being and happiness, organism in context.  Commensurability of alternative medicines

  • Health protection into system, 4 states
    • 1. Safer, healthier people
    • 2. Vulnerable people
    • 3. Afflicted people without complications
    • 4. Afflicted people with complications
  • For #4: have a health response, then secondary and teritiary prevention
  • For #3: primary prvention
  • For #2 and #1, targeted protection
  • Or between #1 and #2, general protection through reducing adverse living conditions
  • Can work on all, different metrics

Impact on decision makers, very accepted in CDC higher management and legislative changes, accept this?  Fifth generation of the systems movement, government and engineering, system of systems, where NSF has decided not to fund SoS?  Connected to Peter Corning or Haken's book?

  • Corning's work was a big influence, but haven't yet had to chance to get to depth on situational.
  • Systems of systems, have a superficial understanding, sympathetic, need a broader view, triage win
  • Acceptance in heterogeneous organizations, early adopters, think we're making great progress
  • Monograph on web site, required reading for all health care professionals, getting endorsement on the foreword was more difficult than writing the whole paper
  • Tipping point in interest in other organizations