Primary Navigation for the CDC Website
CDC en Español
Syndemics Prevention Network
divider
Email Icon Email this page
Printer Friendly Icon Printer-friendly version
divider
 Syndemics
bullet Home
bullet Definition
bullet Overview
bullet Foundations
bullet Monograph - New
bullet Keywords - New
bullet Network
bullet Resources
bullet Contact Us
bullet Return to Division of Adult and Community Health

 Work in Progress
bullet Home
bullet Join


PDF Icon Link to PDF document
Adobe Acrobat Reader needs to be installed on your computer in order to read PDF documents.
Download the Reader
 
Link to nonfederal Web site Link to non-federal Web site
Disclaimer on nonfederal Web sites

Contact Info
Syndemics Prevention Network
4770 Buford Hwy, NE
MS K-67
Atlanta, GA 30341-3717

E-mail: cdcinfo@cdc.gov

divider

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) PDF Icon


Reorienting Public Health Work

Shifting Perspectives

Previous | Next

Seeing through a syndemic orientation involves not just one, but a sequence of shifts in perspective. Each view offers a conceptual and a mathematical formalism that is both comprehensive and context-sensitive: a combination notoriously difficult to achieve using conventional schemes for planning and evaluating public health work (Milstein, 2004b).

In a world where everything connects to everything else, the many transformations that we strive to achieve become more sensible when seen within a defined, negotiated boundary. From this perspective, all relevant dynamics arise from the mutually reinforcing relationships among population health, living conditions, and the public’s power to act. These constructs and their various connections provide a stable frame of reference as well as a rich space for thinking about public health work in a dynamic and democratic context (Figure 6).

Figure 6: Conceptual Boundary for Public Health Work

Figure Showing Conceptual Boundary for Public Health Work

This way of framing the landscape is, however, relatively unique in the health sciences. It not only recognizes the mutually reinforcing connection between health and living conditions, but also regards people as having the power to alter their own health as well as their social and physical environment, even while recognizing that those powers are themselves contingent on characteristics of people and the world in which we live.

The convention in other forms of health research is to begin by conceptualizing a specific disease or risk factor, and then use that as the boundary for all subsequent analysis and action. This point helps clarify why the problem of “confounding” is so central to epidemiologic inquiry. Most epidemiology textbooks introduce the notion of confounding within the first several pages. It is a fundamental principle lying at the core of an epidemiologic orientation. Confounding occurs when the true relationship between an exposure and a disease is obscured by the presence of another factor that is related to both. Variables that function as confounders are described as being of “no intrinsic interest” to the study; sometimes they are labeled “nuisance variables” (Kleinbaum, Kupper, Muller, 1988:9). It is the analyst’s job to exclude confounding influences from being an alternative explanation in the causal relationships that he or she wishes to understand. The problem of confounding takes on a different complexion when the confounder is not another exposure, but a second kind of affliction. For example, the causal relationship between substance abuse and suicide is confounded by depression, which has its own independent relationships to both substance abuse and suicide. The convention in epidemiology is to isolate even the partial effects of an exposure by devising alternative research designs, statistical control procedures, or a combination of methods. The fact remains, however, that the three afflictions are acknowledged to be causally connected, and therein lies a similarity—indeed a complementarity—between the concept of confounding and that of a syndemic. Both perspectives share a concern for identifying relationships between afflictions. But they differ sharply in how those associations are handled conceptually and analytically. Whereas epidemiologists seek to exclude or neutralize the influence of confounders, persons working from a syndemic orientation choose to expand their frame of reference and question what it is that explains the overall dynamic formed by the relating afflictions.

Therefore the conventional approach, with its emphasis on excluding confounders, prohibits a full view of the social system in which different kinds of people, different kinds of problems, and different kinds of problem-solving strategies all interact. The alternative is to first specify a place or a population as the initial referent, and then cooperate with residents or members to address the entire set of forces that constitute the health threat that they face. In this way, a place- or population-based orientation acknowledges more of the plurality that exists throughout the health system (in terms of people, problems, and policies). That alone makes it an essential analytic technique for interpreting the dynamic, democratic forces that we wish to study.

The place- or population-based approach also has the virtue of being more efficient in its application. Rather than proliferating models by the number of different problems found in a group, as is required when each model is bounded by a different disease or risk factor, the alternative approach builds a single model for each place or population, extending further only when it is necessary to expand the inquiry to other groups. Questions about generalizability, in this context, may focus on the extent to which different dynamics are at work in one venue versus another, rather than being confined to conversations about the representativeness of one group for another. It is precisely this virtue that enables a syndemic orientation to be both comprehensive and context-sensitive, an attribute nearly impossible to achieve when a single disease or risk factor is used as the initial referent.

In addition, a greater range of phenomena may be considered when a larger social system is within the analytic frame. Not only is it possible to evaluate changes in the rates at which afflictions form (as is done in conventional epidemiology), but analysts may press on to explore transformations in the conditions that leave people vulnerable to afflictions, as well as changes in the kinds of resources that are organized and cultivated when responding to health threats. This ability to relate health status with changes occurring in other areas of society is an improvement over conventional analytic techniques wherein the conditions that give rise to disease and the activities of people to protect themselves both lie beyond the conceptual boundary (Hancock and Bezold, 1994).

It may be useful to think concretely about three basic types of relations that give rise to change: connection, influence, and direction. One may distinguish among these relations according to the unique properties of the information required to understand each (Table 1).
 
Table 1: Three Types of Relations Supporting a Syndemic Orientation
 
Relation Connection Influence Direction
Questions What links to what? What causes what? Where are we?
When can we go?
Data Proximity Feedback Directional
Visualization Network View Systems View Navigational View

To comprehend connections, one gathers proximity data to discover “what links to what” (e.g., by exchanging information or resources)? To assess causal influences, one examines feedback data, which address the question, “what causes what?” And to direct the course of change, one needs navigational data, which answer the most pragmatic questions of all: “where are we?” and “where can we go from here?” Connection, influence, and direction are the pillars that make a syndemic orientation appropriate and practical as a foundation for routine public health work.

The first step in using this orientation involves seeing more than one problem at a time; this is the crux of the syndemic idea. Within the boundary of a chosen place or population it is possible to focus on health problems individually, and on broader clusters of affliction formed by their relationships (Figure 7). Mapping connections among health problems provides a more complete picture of the health challenge that people face. It highlights ties among different disease processes, which often can pose as much of a problem as the diseases themselves. Sometimes even more so, because the overall burden of affliction in a population can persist unless all major causal forces are taken into account.26

In the most basic sense, a syndemic is defined by the presence of mutually reinforcing relationships or “affliction cross-impacts” (Centers for Disease Control and Prevention, 2001; Homer and Milstein, 2002a; Singer, 1996). If those relationships can be estimated—for example, through effects on incidence, recovery, or severity—then network analysis procedures may be used to measure the strength and structural properties of the entire constellation of disorders (Scott, 2000; Wasserman and Faust, 1994). Having that information, in turn, would bring public health assessments to a new level of sophistication.

Seeing syndemics as structured constellations of affliction might enable us to think more pragmatically about integrated intervention strategies. Even as colleagues continue to address specific epidemics, others operating from a syndemic orientation may begin to devise long-range policies that engage a different set of causal drivers: those associated with larger syndemic networks.

Mapping affliction ties could also improve communication among health professionals and citizen leaders who possess other kinds of expertise. For instance professionals who are trained as disease specialists generally focus on the unique aspects of each disease (represented by the nodes in Figure 7). Whereas leaders without professional training, but who are steeped in neighborhood context, tend to focus on the ties. That may be an oversimplification, but it is frequently true that those who perceive themselves as insiders and who lead health ventures on behalf of themselves and others tend to look beyond specific risks and diseases to see those forces that hold larger constellations of disorders together. As one example, consider the highly contextualized orientation used by leaders of the People’s Health Movement (People's Health Movement, 2004). By collaborating in drawing syndemic networks, health professionals and other citizens would inevitably have to develop a common language, which in turn would help forge a closer, more authentic connection in their work.

Figure 7: Network View

Figure Showing Network View

Next comes the shift from recognizing linked afflictions to understanding causality within a dynamic feedback system (Figure 8). To comprehend why syndemics develop and how they can be controlled, one must step back even farther and take in a broader sweep of time and social space. For example, to explain why a whole pattern of affliction develops (e.g., an intergenerational health inequity), it is necessary to look beyond the immediate causes of prevalent afflictions themselves.

Figure 8: Systems View

Figure Showing Systems View

The analytic boundary must widen to include, at a minimum, interactions among various types of afflictions, the changing character of people’s living conditions (which configure vulnerability to afflictions of many forms), as well as fluctuations in the public’s strength to address them both. A feedback model can relate these various forces to one another, allowing analysts to examine interactions over time and watch trends unfold dynamically. When x and y affect each other, “one cannot study the link between x and y and, independently, the link between y and x and predict how the system will behave. Only the study of the whole system as a feedback system will lead to correct results” (System Dynamics Society, 2002). For most public health problems, particularly those with long time delays like chronic diseases or changes in the physical environment, this approach to modeling yields more precise information about the causal influence of forces that are neither close in time nor near in space to the health events that individuals experience.

Dynamic modeling also allows planners to simulate policy scenarios under different conditions. It offers a virtual world for learning in which rehearsals and controlled experiments can be conducted as a prelude to introducing policies in the real world (Casti, 1997; Foresight and Governance Project, 2002; Maier and Grossler, 2000; Schon and Rein, 1994; Schrage, 2000; Sterman, 2000). This ability to search for policies that can be effective—without the expense, risk, delays, and other barriers to learning inherent in full scale or real time experimentation—expands greatly the range of interventions that can be contemplated.27 And that confers a substantial advantage when crafting actions to protect the health of entire populations.

The navigational view, while focused on the specific goal assuring equitable conditions for health is paradoxically the broadest of all because it frames change in those conditions as the result of choices among any number of possible directions (Figure 9). Those directions may be represented formally using circular statistics, as they are in physical navigation (Batschelet, 1981; Fisher, 1993; Jammalamadaka and Sengupta, 2001); however their meaning in this context pertains entirely to the contours of human values, to the goals we set for our future. This portrayal highlights tensions between advocates of change in one direction versus those of another, thereby allowing an assessment of power differences and the health implications of different policy positions (Krieger, Northridge, Gruskin, et.al., 2003; Mindell, Ison, Joffe, 2003; Taylor and Quigley, 2002; World Health Organization, 2004a). When guided by an explicit moral compass (see page 44), public health workers may use a navigational approach to transcend ad hoc problem solving and exert greater influence in society’s overall governance. It offers tools for keeping us on course toward a safer, healthier future.

Figure 9: Navigational View

Figure Showing Navigational View

The navigational view also corrects a false presumption, now deeply held by many American citizens, that health professionals are the only ones qualified to work on health problems (Scutchfield, Ireson, Hall, 2004; Sirianni and Friedland, 2001b; Snyder, 1999). In fact, genuine movement toward healthier conditions is not possible unless most citizens, working individually and collectively, make healthier choices in their public and private lives (Jennings and Hanson, 1995b; Kari, Boyte, Jennings, 1994). As the renowned historian Henry Sigerist put it:

The people’s health...is a concern of the people themselves. They must want health. They must struggle for it and plan for it. Physicians are merely experts whose advice is sought in drawing up plans and whose cooperation is needed in carrying them out. No plan, however well devised and well intentioned, will succeed if it is imposed on the people. The war against disease and for health cannot be fought by physicians alone. It is a people’s war in which the entire population must be mobilized permanently (Sigerist, 1996:p.227).

The craft of social navigation applies well-established techniques for physical navigation (e.g., positioning, direction-setting, correction) to transformations in the social world (Polynesian Voyaging Society, 2002; Thompson, 2000a). It draws together concepts and methods from fields as diverse as economics, democratic organizing, and evolutionary biology to understand the processes of directed social change (Banathy, 2000; Boyte, 2004b; Chambers and Cowan, 2003; Etzioni, 1991b; Freire, 2000; Gecan, 2002; King, 1967; Laszlo, 2001; Moyer, 2001; Nye and Donahue, 2000; Salk, 1973; Sen, 1999; Sharp, 1973b; Tarrow, 1998). In the 20th century, much of that direction pointed toward dangerous destinations (e.g., global warfare, environmental degradation, profit-driven “disease promotion” (Freudenberg, 2005). Therefore the challenge facing health leaders today and tomorrow is to reposition society on a more healthful course, to engage actively the struggle for conditions in which all people have the opportunity to survive and be healthy.

With these three distinctive points of view—syndemics, systems, and navigation—we see that certain aspects of the overall orientation incorporate modern features of systems science and political thought, but that most of the underlying concepts are not themselves new. In fact, public health historians may well point to times prior to the advent of biomedical specialization when syndemic thinking was even more pronounced. Still, the implications of adhering to this orientation as a formal part of public health work remain largely unexplored, in part because it is only in the last decade that we have developed a language and a set of tools to effectively combine these perspectives with those that shape our prevailing approach to public health work.

Nevertheless, it will likely take decades more for such transformations in thinking and practice to flourish fully. At this early stage, it is apparent that the orientation holds promise for confronting modern health challenges. It does not impose a single, rigid model but instead offers a systems-oriented, politically engaged, and philosophically conscious frame of reference that health professionals and other citizens can use for thinking and working effectively together.
 


26. Some scholars have formalized this idea using the concept of non-specific mortality, which refers to situations where overall mortality in a population remains relatively constant even after dramatic reductions in specific causes of death (Tesh, 1988).

27. This use of simulation modeling is roughly analogous to the use of animal models as a precursor to human biomedical research, though the stakes of animal research are far higher given that it intervenes in living organisms rather than virtual systems.

Previous | Next

Back to top
 

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

  Home | Policies and Regulations | Disclaimer | e-Government | FOIA | Contact Us
Safer, Healthier People

Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, U.S.A.
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435
USA.gov: The U.S. government's official web portal.DHHS Department of Health
and Human Services