Figure 4. Model output for three intervention scenarios compared with the baseline scenario for diabetes complication- related deaths Reprinted with permission from the American Public Health Association 59
the multiple sources and complex interrelationships that determine tobacco-use prevalence and its health effects. A discrete-time dynamic model was developed that simulated smoking prevalence and tobacco-related deaths over a 40-year period. The model employed a first-order Markov process that modeled population growth and age-based rates of tobacco initiation, cessa- tion, and relapse. This model simulated the impact of five policy-level interventions on smoking prevalence: taxes, clean indoor-air laws, strategies to reduce youth access to cigarettes, strategies to promote cessation treatments, and mass-media policies. Researchers used empirical and predicted data for the effects of each of these areas on model parameters. SimSmoke showed the relative contributions made by a variety of different policy interventions (i.e., increasing cigarette prices, introducing smoking bans, introducing media cam- paigns to encourage cessation and prevention, imple- menting additional restrictions on youth access to tobacco, and introducing proactive quitlines) toward the desired outcomes (i.e., reduction in smoking prev- alence and reduction in deaths attributable to to- bacco). Such models can be used to inform decisions about how best to allocate financial resources and formulate policies to optimize a desired public health impact. The focus is on making an efficient population impact to address a complex societal problem (tobacco- use behavior) with an emphasis on outcomes and on multiple causal pathways, feedback loops, and control- systems dynamics that underlie the way the tobacco industry and the public health constituencies vie for their respective goals.
The above examples illustrate the potential for sys- tems science to radically transform the behavioral, social, and population sciences to a degree similar in magnitude to the transformation that systems biology
and bioinformatics are now bringing about in biology. This sentiment is captured in the broad vision for cyber-infrastructure outlined in the Atkins report of the National Science Foundation30:
The opportunity is here to create cyberinfrastruc- ture that enables more ubiquitous, comprehensive knowledge environments that become function- ally complete for specific research communit- ies in terms of people, data, information, tools, and instruments and that include unprecedented capacity for computational, storage, and commu- nication . . . . They can serve individuals, teams and organizations in ways that revolutionize what they can do, how they do it, and who participates.
Programmatic Direction #4. Population Impact
The North Karelia Project60 underscores the value of a multimodal, problem-based approach to a major public health issue. In the 1960s, Finnish men had the world’s highest rate of heart disease mortality. The death rate was especially high in the province of North Karelia, a rural area in the eastern part of Finland. In 1972 officials in North Karelia began a community-based initiative to reduce cardiovascular disease and mortal- ity. The North Karelia project included: (1) cultural interventions addressing traditional Finnish dietary norms to reduce fat intake and to double the consump- tion of fruits and vegetables; (2) media outreach, including health-related news features, educational content, and a national “quit and win” contest; (3) the training of healthcare providers to provide cardiovas- cular risk-factor assessment and counseling for all pa- tients; (4) the engagement of community leaders and workplaces to spearhead health-promotional activities; and (5) policy interventions that included public smok- ing bans, the elimination of tobacco advertising, and taxes earmarked for tobacco control programs.
A variety of research disciplines, including social psychology, nutrition science, marketing, education, primary care medicine, policy, and tobacco control were brought together to design this multilevel inter- vention. The results were impressive: By the early 2000s, the number of deaths of working-age Finnish men from coronary heart disease had plummeted 75%. In North Karelia, the effects were even more pronounced (an 82% reduction in deaths), and life expectancy for men increased 7 years. Much of this reduction in mortality came from reductions in risk factors like high blood pressure, high cholesterol, and smoking, because of nutritional changes and smoking cessation. Today, this project continues to sustain itself with a modest level of public resources.
Another problem with tremendous population im- pact is that of health disparities. If this problem were widely addressed, enormous benefit could be conferred on those affected by these inequalities. Transdisci-
Am J Prev Med 2008;35(2S)