Complexity and the ethics of systems thinking in global health Catherine Womack Bridgewater State University

Systems thinking is… a mindset that views systems and their sub-components as intimately interrelated and connected to each other, believing that mastering our understanding of how things work lies in interpreting interrelationships and interactions within and between systems. T. Adam “Advancing the application of systems thinking in health” Health Research Policy and Systems 12:50

What does systems thinking mean to public health? Building the evidence base for describing and understanding system factors that influence population health Providing public health practitioners and leaders with information for evidence-based, science-driven decision- making and action Responding agilely to the current and emerging issues faced by public health practitioners in an ever-changing system Thomas et al “The value of the “system” in public health services and systems research.” American Journal of Public Health v.105 (Suppl 2) April 2015.

What does complexity mean to philosophers in this context? Multiple levels of description of a system– give rise to shift in which features we recognize, constrain standards of evidence Ex. Obesity, Ebola Multiple viewpoints within some description– give rise to shift in which features we consider salient, force reexamination of criteria for salience Ex. Healthy eating, infection transmission containment Intrinsic value systems in descriptions– must be made explicit and critically examined Ex. Standardized vs. ethnically specific approaches to health, illness, death

What I’ll talk about today– public health, complex systems, ethical frameworks Social networks Patients and practitioners as situated knowers Relational autonomy Social nature of identity Epistemic authority, value of contributions of targeted populations

Complexity and obesity: two models and their limitations Individual medical model Description: excess energy balance viewpoint: curb energy intake, increase energy output values: individual bears responsibility for adherence in absence of effective interventions Obesogenic environmental model Description: economic/political structures governing food supply, infrastructure Viewpoint : leadership initiatives, top-down policies Values: generality, portability, best practices

Social networks– big and little approaches Description: represents complexity through web of contacts, tracking influences, asymmetries Viewpoint: adjustable to find patterns, content of relationships Values: highlights social and contextual nature of identity, relational autonomy Obesity Christakis and Fowler (2007)—patterns of influence Kaufman and Karpati (2007)—ethnographic approach; complexity of eating practices Mulvaney-Day and Womack (2009)— content and context of connections between affective and behavior states through identity

Patients, practitioners as situated knowers Description: experiential, qualitative features Viewpoint: tacit, perspectival, non- generalizable knowledge/know-how of subjects, practitioners Values: confers epistemic authority to embedded subjects Ex. Meaning and importance of “grabability” for eating on the run; “eating salad is hard” Ex. Contact tracing, cooperation and trusted modes of information in Ebola outbreaks

Social-ecological model of health Nancy Krieger: social epidemiology, connections between social determinants of health, health inequities Epidemiology and the People’s Health, Oxford 2011 Lisa Eckenwiler: ecological subjectivity– interdependence and embeddedness of persons in contexts and relations to health equity “Ecological subjects, ethical place-making, and global health equity.” In P. Lenard & C. Straehle (Eds.), Health Inequalities and Global Justice, Edinburgh, Scotland: Edinburgh University Press.

Ways to incorporate complexity in systems thinking on health Encourage and empower multiple viewpoints and knowers Embrace multiple levels of descriptions and participants in systems Look to include and expand types of evidence Remember that standardized doesn’t always equal good/better complexity brings richness of data analysis and respects relational nature of human existence

Thank you Contact info: Catherine A. Womack Dept of Philosophy Bridgewater State University Bridgewater, MA USA