HEALTH, HEALTH CARE, AND HEALTH EDUCATION: Problems, paradigms, and patterns

It is being involved with a phenomenon, being intimately engaged to it, courting it, as it were, that after much perplexity and embarrassment we come upon insight— upon a way of seeing the phenomenon from within. Insight is accompanied by a sense of surprise. What has been closed is suddenly disclosed. It entails genuine perception, seeing anew . . . Paradoxically, insight is knowledge at first sight.

(Heschel 1962)


It seems paradoxical that with practically unlimited access to data, information, high-speed connectivity, and advanced technology that the challenges of contemporary medicine and society are fundamentally about understanding complex human relationships—how to live together in peace and harmony, how to work together for the common good, and how to preserve and prosper in, and with, the environment: “We live in a planetar)' era: all human beings, wherever they may be, are embarked on a common adventure. They should recognize themselves in their common humanity and recognize the cultural diversity inherent in everything human” (Morin 2001: 21).

A very human experience in medicine is illustrated by a true story shared by Professor Ruy Souza, a neurologist and medical educator at the Federal University of Roraima, in Boa Vista, at the most northern tip of Brazil near Venezuela and Guiana:

“... and my patient died happy and cured”

My Yanomami patient had his first seizure in the middle of a festival in his village in northern Brazil, near the border with Venezuela. He was immediately separated from his family. The tribe knew the risks that certain neurological diseases could bring to the community'. A few y'ears ago an outbreak of meningococcal meningitis had devastating effects on the village. Moreover, as a member of an extremely ancient nomadic Indian society that survives by hunting and gathering natural resources

(con tint ted)


in the rainforest, the situation could bring serious risks to families. The case evolved into a status epilepticus, and my patient had to be transferred to a tertiary hospital, where the diagnosis was quick: glioblastoma multiforme, a highly aggressive tumor that occupied much of the right cerebral hemisphere, totally beyond therapeutic possibilities. After a palliative treatment, the patient experienced significant improvement. His movements partially returned and he could now communicate with the healthcare team with the help of a translator. However, in the second week of hospitalization, the patient was isolated in what appeared to be a severe depression; a psychiatric evaluation diagnosed psychotic depression. He refused to eat and talk with members of the staff. He even refused to return to his community. It was necessary to initiate parenteral nutrition.

After 3 weeks, with the help of an anthropologist, it was suggested that we try a consultation with an Indian medicine man. Arriving at the hospital, the healer wanted to talk to me before seeing the patient. He was concerned whether the disease was transmissible and the possible risks to other members of the village. After being assured about the safety of the situation for the others members of the tribe, he performed a religious ritual at the bedside, and declared the patient cured. The result was dramatic. My patient began to interact with everyone, quickly recovered his nutritional status and then asked to return to his tribe. When asked why he did not express his wish to return to his tribe earlier, he told me that it was because now he was feeling healed. With the help of an indigenous agency, he returned to his tnbe.

After a few months, I found the medicine man and asked how my former patient was. He told me that the patient returned and was able to reintegrate into his community, and after 4 months he died. When I said I was sorry, the healer said, “You shouldn’t be, because he died happy and cured!’’ (Petroni Mennin 2016).

This case illustrates the link between medicine, culture, the humanities,1 and health:

Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector but goes beyond healthy life-styles to well-being.

(Ottawa Charter for Health Promotion 1986)

Wellbeing for Dr Souza’s patient came from a coherence and a wholeness which was more accessible to him from the medicine man than from the modern biomedical model of medicine (Capra 1982; Engel 1995).

Medicine/health and the humanities have always been interconnected. It’s as if they are fraternal twins, inseparable in their beginnings and then, over time, they drifted apart on a sea of scientific and technological progress, becoming estranged from one another. Today, feedback from patients, students, and a handful of artists, alternative healers, and physicians, among others, has rekindled an interest in reuniting the humanities, health, and health care (Bleakley 2006, 2010; Bleakley, Bligh, and Browne 2011). The humanities and health are each an expression of the whole of the human experience grounded in observation, sense-making, and action. Observation, sense-making, and action involve a continuous flow (Csikszentmihalyi 1996) and exchange of information, collecting and sorting through data, and looking for patterns.

The present chapter uses practical examples and theory together to show the link between medicine, humanities, and health. The authors argue that contemporary medical practice—and the education tor that practice—are experiencing a paradigm shift. The paradigm is shifting from health as the absence of disease and as problems with known explanations and solutions, to health and education tor practice as complex patterns in complex adaptive systems (CAS), not solvable in the traditional sense of having a known solution. The authors examine and question underlying assumptions about problems and patterns. They argue that solvable problems and complex health patterns arise by completely different mechanisms. The Containers/Differences/ Exchanges (CDE) model for self-organisation in human systems is presented to clarify both theoretical and practical approaches to complex patterns through the lens of Human Systems Dynamics (HSD), a field of study at the intersection of systems thinking, effective practice, and social and complexity sciences (see: It supports both description and explanation of patterns in CAS, how they form, how they are influenced, and how they change. Finally, Adaptive Action is presented as a practical and disciplined method by which to take informed action in CAS. Illustrative examples are presented throughout the chapter

The nature of patterns

We perceive the world as dynamical patterns. They are everywhere and they come in all shapes and sizes, for example: the weather, health, information technology, relationships, a functional team, family, work, education, public health, safe driving, people crossing the street, and so forth. Patterns are the foundational and functional unit with which, and from which, we inter meaning. They are how we ‘know’ ourselves and the world we cohabit (Rosch, 1999).

Patterns can be defined as “similarities, differences, and connections that have meaning across space and time” (Eoyang and Holladay 2013). A pattern is generated by the dynamical (complex) interaction and interdependence of its parts. Similarly, patterns organise themselves into systems (Bertalanffy 1973; Dooley, 1996; Cilliers 1998; Eoyang 2001; Eoyang and Holladay 2013). It is the pattern of the whole that we perceive first and with which we connect. Subsequently, we become aware of and name patterns as concepts and analogies (Thelen and Smith 1994; Rosch 1999; Tschacher and Haken 2007; Hofstadter and Sander 2013). The HSD Institute recognises patterns that occur in both predictable and unpredictable complex situations as “similarities, differences and the connections they make in a system over time and across space” (Eoyang and Holladay 2013), where:

Similarities give coherence and meaning . . . differences generate tension in the present and connections from the past set conditions for future transformations of the pattern. These three conditions (similarities, differences and connections), and their relationships to one another, set the stage tor meaning making and help us to articulate reality in a way that is conscious and can be shared.

(ibid.: 43)

It thus becomes essential to understand and explain both predictable and unpredictable patterns in ways that we understand as both true and useful—in ways that help us to stay relevant as we engage with a rapidly changing environment and to learn to take informed action within the uncertain health challenges we face today.

Learners, teachers, clinicians, patients, and artists seek patterns that enable understanding. They seek a degree of control and would like to be able to predict what will happen. Prediction, replication, control, and reliability depend on clear measurable boundaries: differences and similarities with relatively strong stable connections. Examples include measuring blood pressure, setting a simple fracture, and one-best-answer multiple-choice questions. These patterns have few variables that make a difference, have known and knowable answers, and, when problems arise, it is clear what needs to be done. There are likely to be few surprises or complications. There are a finite and knowable number of possibilities and thus such patterns are said to be ‘low dimensional’ (Table 4.1).

On the other hand, there are patterns that follow a different set of rules. They can’t be replicated or predicted, don’t have known solutions, and can’t be controlled. There are many interacting parts and many levels of organisation. Such patterns occur in systems that are bounded, yet open and sensitive to outside influences. In human systems, success looks different to different people. Examples include small-group problem-based learning (Mennin 2007), chronic illness, preventive medicine, community health sendees, and existing health disparities (Sweeney and Griffiths 2002; Holt 2004; Kernick 2004; Sweeney 2006). Each pattern and system is unique, like Dr Souza’s patient, so no evidence-based practice will be relevant ever)’ time. Because of massive interdependencies and unintended consequences, best practices in one place may be worse than nothing in another place or time. In these situations, a different set of tools is needed; tools that function well in CAS. They include the tools, models and methods from the HSD Institute.

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