Overview of

System Dynamics Simulation Modeling

Bobby Milstein
Syndemics Prevention Network
Centers for Disease Control and Prevention
Atlanta, Georgia
bmilstein@cdc.gov

Syndemics
Prevention Network

Systems Thinking and Modeling Workshop

Office of Disease Prevention and Health Promotion
Bethesda, MD
May 8, 2006

Research Imperatives for Protecting Health

Typical Current State
Static view of problems that are
studied in isolation
Proposed Future State
Dynamic systems and syndemic
approaches
"Currently, application of complex
systems theories or syndemic science
to health protection challenges
is in its infancy.
-- Julie Gerberding

Syndemics
Prevention Network

Gerberding JL. Protecting health: the new research imperative.

Journal of the American Medical Association 2005;294(11):1403-1406.

Milestones in the Recent Use of

System Dynamics Modeling at CDC
AJPH
Systems
Issue

Science Seminars and

Professional Development Efforts
CDC Evaluation
Framework
Recommends
Logic Models

1999

SD Emerges as a
Promising Methodology

2000

2001

Syndemics
Modeling

System Change Initiatives Encounter

Limitations of Logic Models and
Conventional Planning/Evaluation Methods

2002

Neighborhood
Assistance
Game

2003

Diabetes
Action Labs*

2004

Prevention Network

* Dedicated multi-year budget

2005

2006

Fetal & Infant

Obesity Over
Health Goal-Setting the Lifecourse*

Upstream-Downstream
Investments

Syndemics

ODPHP
Modelers
Meeting

Hypertension
Prevention &
Control *

System Dynamics Was Designed to Address

Problems Marked By Dynamic Complexity
Origins
Jay Forrester, MIT (from late 1950s)
Public policy applications starting late 1960s
Good at Capturing
Differences between short- and long-term
consequences of an action
Time delays
(e.g., transitions, detection, response)
Accumulations
(e.g., prevalence, capacity)
Behavioral feedback
(e.g., actions trigger reactions)
Nonlinear causal relationships
(e.g., effect of X on Y is not constant)
Differences or inconsistencies in goals/values
among stakeholders
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Syndemics
Prevention Network

Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities. American Journal of Public
Health 2006;96(3):452-458.

Understanding Dynamic Complexity

From a Very Particular Distance
{System dynamics studies problems} from a very particular distance',
not so close as to be concerned with the action of a single individual, but not so far away
as to be ignorant of the internal pressures in the system.
-- George Richardson

Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68.

Meadows DH. Leverage points: places to intervene in a system. Sustainability Institute, 1999.
Available at <http://www.sustainabilityinstitute.org/pubs/Leverage_Points.pdf>.
Syndemics
Prevention Network

Richardson GP. Feedback thought in social science and systems theory. Philadelphia, PA: University of Pennsylvania Press, 1991.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.

Tools for Policy Analysis

Events
Increasing:
Increasing:
Depth
Depthof
ofcausal
causaltheory
theory

Patterns

Degrees
Degreesof
ofuncertainty
uncertainty
Robustness
Robustnessfor
forlongerlongerterm
projection
term projection
Value
Valuefor
fordeveloping
developing
policy
insights
policy insights

Structure

Syndemics
Prevention Network

Time Series Models

Describe trends
Multivariate Stat Models
Identify historical trend drivers
and correlates

Dynamic Simulation Models

Anticipate new trends, learn
about policy consequences,
and set justifiable goals

How Many Triangles Do You See?

Wickelgren I. How the brain 'sees' borders. Science 1992;256(5063):1520-1521.

Syndemics
Prevention Network

Boundary Critique

Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking.
Reflective Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf
Syndemics
Prevention Network

Boundary Critique

Syndemics
Prevention Network

Ulrich W. Reflective practice in the civil society: the contribution of critically systemic thinking. Reflective
Practice 2000;1(2):247-268. http://www.geocities.com/csh_home/downloads/ulrich_2000a.pdf

Health System Dynamics

Public
Work
Society's Health
Response

General
Protection

Targeted
Protection

Primary
Prevention

Demand for
response

Becoming safer
and healthier

Safer
Healthier
People

Becoming
vulnerable

Tertiary
Prevention

Secondary
Prevention

Vulnerable
People

Becoming
afflicted

Afflicted
without
Complications

Developing
complications

Adverse Living
Conditions

Milstein B, Homer J. The dynamics of upstream and downstream: why is

Afflicted with
Complications

Dying from
complications

Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work
so hardand
forwhat
thecan
health
system
work
upstream,
and
what
can
be done
upstream,
be done
about it? to
CDC
Futures
Health Systems
Work
Group;
Atlanta,
GA; December 3, 2003.

about it?JL.CDC
Health
Systems
Workgroup;
GA;12,2003.
Gerberding
CDC'sFutures
futures initiative.
Atlanta,
GA: Public
Health TrainingAtlanta,
Network; April
2004.
Syndemics
Prevention Network

Homer JB, Hirsch GB. System dynamics modeling for public health: background and opportunities.
American Journal of Public Health 2006;96(3):452-458.

Understanding Health as Public Work

Public Work
-

Citizen Involvement
in Public Life

Society's Health
Response

General
Protection

Targeted
Protection

Primary
Prevention

Tertiary
Prevention

Secondary
Prevention
Demand for
response

Becoming safer
and healthier

Safer
Healthier
People

Becoming
vulnerable

Vulnerable
People

Adverse Living
Conditions

Fraction of Adversity,
Vulnerability and Affliction
Borne by Disadvantaged
Sub-Groups (Inequity)

Syndemics
Prevention Network

Becoming
afflicted

Afflicted
without
Complications

Developing
complications

Afflicted with
Complications

Dying from
complications
Vulnerable and
Afflicted People

Social
Division

Public
Strength

Testing Dynamic Hypotheses

Public Work

Citizen Involvement
in Public Life

Society's Health
Response

General
Protection

Targeted
Protection

Primary
Prevention

Public
Strength
-

Secondary
Prevention

Tertiary
Prevention
Demand for
response

Becoming safer
and healthier

Safer
Healthier
People

Becoming
vulnerable

Vulnerable
People

Adverse Living
Conditions

Fraction of Adversity,
Vulnerability and Affliction
Borne by Disadvantaged
Sub-Groups (Inequity)

Becoming
afflicted

Afflicted
without
Complications

Developing
complications

Afflicted with
Complications

Dying from
complications
Vulnerable and
Afflicted People

Social
Division

-- How can we learn about the consequences of actions in a system of this kind?
-- Could the behavior of this system be analyzed using conventional epidemoiological methods
(e.g., logistic or multi-level regression)?

Syndemics
Prevention Network

Learning In and About Dynamic Systems

In [dynamically complex] circumstances simulation becomes the
only reliable way to test a hypothesis and evaluate the likely effects of policies."

-- John Sterman

Dynamic Complexity Hinders

Benefits of Simulation/Game-based Learning

Generation of evidence
(by eroding the conditions
for experimentation)

Formal means of evaluating options

Experimental control of conditions

Learning from evidence

(by demanding new heuristics
for interpretation)

Compressed time

Complete, undistorted results

Acting upon evidence

(by including the behaviors
of other powerful actors)

Actions can be stopped or reversed

Visceral engagement and learning

Tests for extreme conditions

Early warning of unintended effects

Opportunity to assemble stronger support

Sterman JD. Learning from evidence in a complex world. American Journal of Public Health (in press).
Syndemics
Prevention Network

Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin
McGraw-Hill, 2000.

System Dynamics Modeling Supports

Navigational Policy Dialogues
Prevalence of Diagnosed Diabetes, US
40
Historical
Data

e
Wh

Million people

30

kov
Mar

re?

M
ing
ast
c
e
For

l
ode

Simulation
Experiments
in
Action Labs

What?
20

Ho
w?

10

0
1980

Wh
o?

y?
Wh
1990

Markov Model Constants

Incidence rates (%/yr)
Death rates (%/yr)
Diagnosed fractions
(Based on year 2000 data,
per demographic segment)

2000

2010

2020

2030

2040

2050

Honeycutt A, Boyle J, Broglio K, Thompson T, Hoerger T, Geiss L, Narayan K. A dynamic markov model for forecasting diabetes
prevalence in the United States through 2050. Health Care Management Science 2003;6:155-164.
Syndemics
Prevention Network

Jones AP, Homer JB, Murphy DL, Essien JDK, Milstein B, Seville DA. Understanding diabetes population dynamics through
simulation modeling and experimentation. American Journal of Public Health 2006;96(3):488-494.

Simulations for Learning in Dynamic Systems

All models are wrong. Some are useful.

Multi-stakeholder
Dialogue

Dynamic Hypothesis (Causal Structure)

Plausible Futures (Policy Experiments)

Deaths per Population
0.0035

0.003

s
Ba

0.0025

Mixed

Upstream

0.002

ea
str
n
w
Do

0.0015
1980

1990

2000

2010
2020
Time (Year)

2030

2040

2050

Blue: Base run; Red: Clinical mgmt up from 66% to 90%;

Green: Caloric intake down 4% (99 Kcal/day);
Black: Clin mgmt up to 80% & Intake down 2.5% (62 Kcal/day)

Morecroft JDW, Sterman J. Modeling for learning organizations. Portland, OR: Productivity Press, 2000.
Sterman JD. Business dynamics: systems thinking and modeling for a complex world. Boston, MA: Irwin McGraw-Hill, 2000.
Syndemics
Prevention Network

Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514.
Sterman JD. All models are wrong: reflections on becoming a systems scientist. System Dynamics Review 2002;18(4):501-531.

Simulation Experiments
Open a Third Branch of Science

The complexity of our mental models vastly exceeds our ability

to understand their implications without simulation."

-- John Sterman
What?
Prevalence of Obese Adults, United States

?
hy
W

?
ere
Wh

Ho
w?

Wh
o?
Data Source: NHANES

2010

2020

Simulation is a third way of doing science.

Like deduction, it starts with a set of explicit
assumptions. But unlike deduction, it does not
prove theorems. Instead, a simulation generates
data that can be analyzed inductively. Unlike typical
induction, however, the simulated data comes from
a rigorously specified set of rules rather than direct
measurement of the real world. While induction can
be used to find patterns in data, and deduction can
be used to find consequences of assumptions,
simulation modeling can be used as an aid to
intuition.
-- Robert Axelrod

Syndemics
Prevention Network

Axelrod R. Advancing the art of simulation in the social sciences. In: Conte R, Hegselmann R, Terna P, editors. Simulating Social
Phenomena. New York, NY: Springer; 1997. p. 21-40. <http://www.pscs.umich.edu/pub/papers/AdvancingArtofSim.pdf>.
Sterman JD. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, MA: Irwin McGraw-Hill, 2000.

Questioning the Character of Public Health Work

PUBLIC HEALTH WORK

SOCIAL NAVIGATION
(governing movement)
Directing Change
Who does the work?
By what means?
According to whose values?
Charting Progress
How are conditions changing?
In which directions?

SYSTEMS
THINKING & MODELING
(understanding change)
What causes population
health problems?

Innovative
Health
Ventures

How are efforts to protect

the publics health organized?
How and when do health
systems change (or resist
change)?

PUBLIC HEALTH
(setting direction)
What are health leaders
trying to accomplish?

Syndemics
Prevention Network

EXTRAS

Syndemics
Prevention Network

Potential Users and Uses of

Health SD Simulation Models

Planners/Evaluators/Media: Chart Progress Toward Goals

Researchers: Better Measurement and New Knowledge

Prevention Network

Integrate diverse data sources into a single analytic environment

Infer properties of unmeasured or poorly measured parameters
Analyze historical drivers of change
Locate areas of uncertainty to be addressed in new research

Policy Makers: Convene Multistakeholder Action Labs

Syndemics

Define a status quo future

Define alternative futures based on policy scenarios
Define types of information to be routinely collected
Track and interpret trajectories of change
Estimate how strong interventions must be to make a difference

Understand how a dynamically complex system functions

Discover short- and long-term consequences of alternative policies
Prepare for difficult patterns of change (e.g., worse-before-better)
Consider the cost effectiveness of alternative policies
Explore ways of combining and aligning policies for better results
Increase policy-makers motivation to act differently

Others

Possible Roles for System Dynamics in Public Health

SD is especially well-suited for studying

Syndemics
Prevention Network

Individual diseases and risk factors

Examining momentum and setting justifiable goals

Life course dynamics

Following health trajectories across life stages

Mutually reinforcing afflictions (syndemics)

Exploring interactions among related afflictions, adverse living conditions,
and the publics capacity to address them both

Capacities of the health protection system

Understanding how ambitious health ventures may be configured without
overwhelming/depleting capacity--perhaps even strengthening it

Value trade-offs
Analyzing phenomena like the imbalance of upstream-downstream effort,
growth of the uninsured, rising costs, declining quality, entrenched inequalities

Organizational management
Linking balanced scorecards to a dynamic understanding of processes

Group model building and scenario planning

Bringing more structure, evidence, and insight to public dialogue and judgment

Steps for Developing Dynamic Policy Models

Identify
Identifyaa
Persistent
PersistentProblem
Problem
Graph
Graphits
itsbehavior
behavior
over
time
over time
Create
Createaa
Dynamic
DynamicHypothesis
Hypothesis
Identify
and
Identify andmap
mapthe
the
main
causal
forces
that
main causal forces that
create
createthe
theproblem
problem

Syndemics
Prevention Network

Convert
Convertthe
theMap
Map
Into
a
Simulation
Into a SimulationModel
Model
Formally
Formallyquantify
quantifythe
the
hypothesis
hypothesisusing
usingall
all
available
evidence
available evidence

Run
RunSimulation
Simulation
Experiments
Experiments
Compare
Comparemodels
modelsbehavior
behaviortoto
expectations
expectationsand/or
and/ordata
datatoto
build
buildconfidence
confidenceininthe
themodel
model

Learn
LearnAbout
AboutPolicy
Policy
Consequences
Consequences
Test
Testproposed
proposedpolicies,
policies,
searching
for
ones
searching for onesthat
thatbest
best
govern
governchange
change

Choose
ChooseAmong
Among
Plausible
Futures
Plausible Futures
Discuss
Discussvalues
valuesand
and
consider
considertrade-offs
trade-offs

Enact
EnactPolicies
Policies
Build
power
Build powerand
and
organize
actors
organize actorstoto
establish
establishchosen
chosenpolicies
policies