Policy Points:
Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community.
One reason is the considerable influence of the “commercial determinants of health”: NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking.
This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions.
Context
The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual‐level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors.

Methods
Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy.

Findings
Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions.

Conclusions
It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1468-0009.12339

Systems Thinking as a Framework for Analyzing Commercial Determinants of Health

Water in crisis: paths to sustainable water use

Waterborne pathogens have attracted a great deal of attention in the public health sector over the last several decades. However, little is known about the pathogenic microorganisms in urban water systems. In this study, the bacterial community structure of 16 typical surface waters in the city of Beijing were analyzed using Illumina MiSeq high-throughput sequencing based on 16S rRNA gene. The results showed that Bacteroidetes, Proteobacteria and Actinobacteria were the dominant groups in 16 surface water samples, and Betaproteobacteria, Alphaproteobacteria, Flavobacteriia, Sphingobacteriia and Actinobacteria were the most dominant classes. The dominant genus across all samples was Flavobacterium. In addition, fifteen genus level groups of potentialy pathogenic bacteria were detected within the 16 water samples, with Pseudomonas and Aeromonas the most frequently identified. Spearman correlation analysis demonstrated that richness estimators (OTUs and Chao1) were correlated with water temperature, nitrate and total nitrogen (p < 0.05), while ammonia-nitrogen and total nitrogen were significantly correlated with the percent of total potential pathogens (p ≤ 0.05). These results could provide insight into the ecological function and health risks of surface water bacterial communities during the process of urbanization.

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Bacterial communities and potential waterborne pathogens within the typical urban surface waters.

The extent to which government should partner with business interests such as the alcohol, food, and other industries in order to improve public health is a subject of ongoing debate. A common approach involves developing voluntary agreements with industry or allowing them to self-regulate. In England, the most recent example of this was the Public Health Responsibility Deal (RD), a public⁻private partnership launched in 2011 under the then Conservative-led coalition government. The RD was organised around a series of voluntary agreements that aim to bring together government, academic experts, and commercial, public sector and voluntary organisations to commit to pledges to undertake actions of public health benefit. This paper brings together the main findings and implications of the evaluation of the RD using a systems approach. We analysed the functioning of the RD exploring the causal pathways involved and how they helped or hindered the RD; the structures and processes; feedback loops and how they might have constrained or potentiated the effects of the RD; and how resilient the wider systems were to change (i.e., the alcohol, food, and other systems interacted with). Both the production and uptake of pledges by RD partners were largely driven by the interests of partners themselves, enabling these wider systems to resist change. This analysis demonstrates how and why the RD did not meet its objectives. The findings have lessons for the development of effective alcohol, food and other policies, for defining the role of unhealthy commodity industries, and for understanding the limits of industry self-regulation as a public health measure.

https://www.mdpi.com/1660-4601/15/12/2895/pdf

The Public Health Responsibility Deal: Using a Systems-Level Analysis to Understand the Lack of Impact on Alcohol, Food, Physical Activity, and Workplace Health Sub-Systems.

The UK government has an ambitious goal to reduce carbon emissions from the housing stock through energy efficiency improvements. This single policy goal is a strong driver for change in the housing system, but comes with positive and negative “unintended consequences” across a broad range of outcomes for health, equity and environmental sustainability. The resulting policies are also already experiencing under-performance through a failure to consider housing as a complex system. This research aimed to move from considering disparate objectives of housing policies in isolation to mapping the links between environmental, economic, social and health outcomes as a complex system. We aimed to support a broad range of housing policy stakeholders to improve their understanding of housing as a complex system through a collaborative learning process. We used participatory system dynamics modelling to develop a qualitative causal theory linking housing, energy and wellbeing. Qualitative interviews were followed by two interactive workshops to develop the model, involving representatives from national and local government, housing industries, non-government organisations, communities and academia. More than 50 stakeholders from 37 organisations participated. The process resulted in a shared understanding of wellbeing as it relates to housing; an agreed set of criteria against which to assess to future policy options; and a comprehensive set of causal loop diagrams describing the housing, energy and wellbeing system. The causal loop diagrams cover seven interconnected themes: community connection and quality of neighbourhoods; energy efficiency and climate change; fuel poverty and indoor temperature; household crowding; housing affordability; land ownership, value and development patterns; and ventilation and indoor air pollution. The collaborative learning process and the model have been useful for shifting the thinking of a wide range of housing stakeholders towards a more integrated approach to housing. The qualitative model has begun to improve the assessment of future policy options across a broad range of outcomes. Future work is needed to validate the model and increase its utility through computer simulation incorporating best quality data and evidence. Combining system dynamics modelling with other methods for weighing up policy options, as well as methods to support shifts in the conceptual frameworks underpinning policy, will be necessary to achieve shared housing goals across physical, mental, environmental, economic and social wellbeing.

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Integrated decision-making about housing, energy and wellbeing: a qualitative system dynamics model.

Background: As human populations become more and more urban, decision-makers at all levels face new challenges related to both the scale of service provision and the increasing complexity of cities and the networks that connect them. These challenges may take on unique aspects in cities with different cultures, political and institutional frameworks, and at different levels of development, but they frequently have in common an origin in the interaction of human and environmental systems and the feedback relationships that govern their dynamic evolution. Accordingly, systems approaches are becoming recognized as critical to understanding and addressing such complex problems, including those related to human health and wellbeing. Management of water resources in and for cities is one area where such approaches hold real promise. Results: This paper seeks to summarize links between water and health in cities and outline four main elements of systems approaches: analytic methods to deal with complexity, interdisciplinarity, transdisciplinarity, and multi-scale thinking. Using case studies from a range of urban socioeconomic and regional contexts (Maputo, Mozambique; Surat and Kolkata, India; and Vienna, Austria). Conclusion: We show how the inclusion of these elements can lead to better research design, more effective policy and better outcomes.

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Ranjit Biswas

Papers

Improving health in cities through systems approaches for urban water management