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Hygeia's Constellation Hygeia’s Constellation Navigating Health Futures in a Dynamic and Democratic World by Bobby Milstein Department of Health and Human Services • Centers for Disease Control and Prevention • Syndemics Prevention Network April 15, 2008 Hygeia’s Constellation: Navigating Health Futures in a Dynamic and Democratic World Each life is a story. Some are long, rich epics filled with happiness, health, and rewarding work, while others—-far too numerous-—are punctuated by excessive adversity, affliction, and loss. Often, helping to define and ameliorate those extremes is another kind of story: the rapidly evolving drama of our collective effort to establish and maintain the conditions necessary for health. In Hygeia’s Constellation, the focus is on both health protection, over time and across places, as well as health equity. It is a unique inquiry into the dynamic and democratic dimensions of health in the 21st Century. Hygeia’s Constellation points the way toward a promising new horizon for thinking and action at a time when health threats and the provision of healthcare are increasingly complicated, and health professionals of all types are challenged to respond. Building on past and current innovations, Bobby Milstein asks us to think differently: to consider more than one problem at a time; to see the health landscape in larger, more dynamic terms; and to question what exactly each of us can do, across our respective spheres of influence, to create the conditions for a healthier, more equitable future. Health systems in the United States and around the world are rapidly changing, and need to be guided by an orientation in which problems are confronted in a holistic manner that acknowledges both their contours and connections. The grave dangers and abundant opportunities that characterize today’s health protection enterprise require a broad outlook to navigate health futures-—the alternative trajectories that could unfold for the people’s health over time. Hygeia’s Constellation is an arresting resource that should be read by every health professional. Readers will be inspired and challenged to learn how their work, along with that of their fellow citizens, may indeed provide the leverage necessary to create a healthier, happier, and more prosperous future for all. Please join us in exploring this unique perspective and its power to transform our daily efforts to protect the public’s health and achieve health equity. Julie Louise Gerberding, M.D., M.P.H. Director, Centers for Disease Control and Prevention Administrator, Agency for Toxic Substances and Disease Registry Acknowledgments This report on the directed nature of public health work was created through interactions with scores of fellow travelers. Like all worthy voyages, its rewards lay in the unforeseen turns and surprising vistas found along the way. Several people, in particular, must be mentioned by name, for without their guidance this exploration might have stalled in one or more dead ends. Nainoa Thompson provided a compelling example of what it means to be both a student and teacher of navigation; Jack Homer masterfully managed to explain a simple way of learning about complexity; Dick Jackson was quick to go public with big ideas; Glenda Eoyang served as a consistently sensitive and astute sounding board; Nicole Lezin contributed her talents for listening, organizing, and writing; Joanna Davidson was a boundless source of inspiration; and Jasper Milstein opened new horizons just by arriving. In addition, Union Institute & University committee members–Elizabeth Minnich, Michael Quinn Patton, Marshall Kreuter, Kate MacQueen, Harry Boyte, Ruth Ann Bramson, Don Klein, and Alan Barstow–helped with an unswerving combination of patient faith and pressing enthusiasm. Finally, many friends and colleagues at the CDC not only saw value in this inquiry, but also provided the freedom to pursue it. Hygeia’s Constellation Navigating Health Futures in a Dynamic and Democratic World by Bobby Milstein THE CENTERS FOR DISEASE CONTROL AND PREVENTION Syndemics Prevention Network April 15, 2008 Contact Information Bobby Milstein, PhD, MPH Syndemics Prevention Network Centers for Disease Control and Prevention Tel: 770-488-5528 E-mail: [email protected] Web: http://www.cdc.gov/syndemics Disclaimer: The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. Imagining how to create a city in which life would be good is Hygeia’s art, which is far more complex [than swallowing a pill]. For a city in which life would be good implies that there is none of that noise to which we adapt by losing our hearing, none of those fumes to which we adapt by developing chronic bronchitis, and none of those constructions that prevent the eye from venturing to the horizon. Yes, that’s Hygeia’s art, but it can also become a science, a science that tries to understand the basic requirements permitting human nature to express itself totally. Dubos and Escande, 1979:87 Navigating Health Futures in a Dynamic and Democratic World ABSTRACT Effective public health work is rooted in traditions Because public health workers aspire to assure safer, of concerned, humane, directed science. healthier conditions—which are politically contested However, the field has changed significantly since and constantly in flux—the concepts, methods, its formalization in the mid-19th century, and even and moral principles that shape health policy must today, innovators are reshaping its underlying themselves resemble the features of dynamic, orientations. This study examines the origins and democratic systems. Hence, a second purpose of this implications of one such innovation, the recent study is to explore what an explicitly dynamic and introduction of the term syndemic, along with democratic view of public health work might entail. related shifts in thinking and action that occur Examples provided here illustrate how innovators are when operating from a syndemic orientation. learning to better acknowledge the interdependency Distinguishing between a single epidemic and of people in places; map the dynamics that govern the phenomenon of syndemics expands, in very patterns of health, vulnerability, and affliction; particular ways, the conceptual, methodological, anticipate a range of plausible health futures; and work and moral dimensions of public health work. This democratically with other citizens to build the public perspective is a reminder that epidemiologic strength needed for navigating change and expanding principles have been applied largely to the first tier people’s freedoms. This inquiry joins conversations from of a highly complicated health system. It also alerts three spheres of scholarship: public health, systems us to the inevitability of boundary judgments, the thinking and modeling, and social navigation. All of need to actively critique those judgments, and the these inform our collective efforts to navigate health possibilities that exist for orienting the entire health futures through the processes of setting direction, protection enterprise in new directions. understanding change, and governing movement. Navigating Health Futures in a Dynamic and Democratic World Table of Contents PROLOGUE .......................................................................................................................................................1 INTRODUCTION ...............................................................................................................................................3 Hygeia’s Constellation .................................................................................................................................3 Purposes of this Document .........................................................................................................................5 Joining Scholarly Conversations .................................................................................................................7 NAVIGATING HEALTH FUTURES ...................................................................................................................16 VALUING CONDITIONS ................................................................................................................................17 Protecting What You Consider Special: The Star Path of Ke Ala Hoku .....................................................17 Characterizing Public Health Work ........................................................................................................... 21 Seeing Conditions as Freedoms .............................................................................................................. 23 CRAFTING CONDITIONS .............................................................................................................................. 26 Revisiting Broad Street: A Cautionary Tale ................................................................................................26 From Broad Street to East Brooklyn: Choosing a Future ..........................................................................30 PERCEIVING DYNAMIC CONDITIONS .........................................................................................................34 The Era of Relative Clarity .........................................................................................................................34 The Era of Growing Confusion ..................................................................................................................36
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