Health, Complexity and Warm Data
Nora Bateson and Aidan Ward
Health conditions and conditions of health.
This paper is an invitation to consider the similarities in criteria between the health of the body, and the organization of a health care system. Both are systems, defined and vitalized by ever combining interactions within still larger systems. Health in the body is not merely a mechanistic goal, but rather, it is a consequence of a person’s living conditions: their sleep, exercise, economic security, emotional security, intellectual inspiration, clean air, clean water, good food, and the ecology of their microbiome. All of these conditions are then pivoted upon their access to a healthcare system that can assist when there are imbalances, pathologies and incoherence in the body’s own processes of equilibrium. A healthcare system is like the body in that it exists within an interdependency of social institutions, economic vitality, education, industry that supports healthy products, laws and regulations that protect the health of citizens, media and culture that produces messages of health, science and technology, and even religious support of healthy habits. There is an important congruency between these two systems of the body and the health care system, they share certain characteristics of “complexity”.
At present, as healthcare systems are in dire need, and societal health is threatened by increasing illness, we can say that both systems are sick. The systems are unable to generate life affirming relationships within their larger systems. They are both depleting, declining, and face dangerous devastation in coming decades. Just as there is no single cause obesity, or cancer, there will be no single cure. Treatment must include a shift in living conditions of the patient to support new habits, new nourishment, and new relationships with the world. Likewise pumping money into a health care system will not necessarily improve its efficacy. This has been proven again and again. The conditions in which health is produced is another frame through which to assess the possibilities of how a healthcare system might be more robust. How might we think of these two systems, the body and the medical system as similar, in sickness and in health?
It is also useful to distinguish the disease that characterises a particular sickness from the illness experienced by the person who has the disease. The healthcare system studies diseases and the body processes that produce them, with a view to preventing the disease process. But preventing the disease may do little to alleviate the illness and the underlying causes of the illness. In a similar way the healthcare systems are subject to frenetic mending of processes when they fail and to endless improvements in efficiency. But none of this activity addresses the problems healthcare systems face in their wider social and political systems.
What is Health?
Health can be seen as a marker, an indicator, a sign. It indicates that an awe-inspiring set of interlocking systems are working together. Health is thoroughly trans-contextual: it cannot be arbitrarily contained in a particular context. For instance, trying to describe health only in biomedical terms becomes nonsensical very quickly. The complexity necessary to cultivate health in a changing environment is not negotiable: we either act in ways that maintain health or we do not, although the distinction may not be obvious at the time. Although there is a spectrum of resilience in our health, the scope needed cannot be sensibly limited. There are many interdependent contexts we rely on to generate our health.
We can zoom right in to look at health or we can zoom right out: it is the same thing through a different window or lens. We can describe an individual as healthy or not, and a healthy individual will have healthy interdependent organs and a healthy context of microbial life and other aspects of the local environment. A single cell can be healthy. But we can also describe a family unit as healthy, a community as healthy and a society as healthy, or not. And these scales of study are far from being separable. In a very bounded example, it seems that loneliness is a bigger risk factor for health than smoking. There is sense in calling an ecosystem healthy and a sense in which this is the foundational meaning. A thriving ecosystem has an almost infinite number of ways to stabilise and regulate itself and the environment it depends on.
The structure of the argument of this paper
The notion of complexity as necessary and as a resource, leads to a description of warm data which is an approach to engaging with this complexity and its dynamics. The urgency of tackling this research programme is underscored by sketching the violence that is implicit is current approaches to healthcare, and by the understanding of how self-defeating this can be. Then there is a sketch of how the funding of healthcare is overwhelmed by the same set of misconceptions of complexity. Finally there are some brief case studies from our work to indicate the range of practical issues covered.
Health is not a static condition, only disturbed by illness or trauma. It is completely relational and is produced in the interaction of multiple contexts each moment and each day. Each context that is significant in the production of health changes as it learns about changes in other contexts. This is the heart of the complexity needed to produce health. Far from looking to limit the contextual description of the situation and to manage advice on the maintenance of health, in general health is produced by adding complexity. More trans-contextual learning is needed to regain balance when it is lost. Many contexts need to be taken into account: every time we look to simplify what is really necessary we merely find out that we have not sufficiently understood.
Our mentality in the west is not like this. We in the west long to identify problems and fix them. In healthcare the incentives are to draw a boundary around some “health conditions” that can be treated in isolation from other conditions. Healthcare is much better at hip replacements and eye surgery than at treating auto-immune conditions. As healthcare tries to deal with “conditions” that are thoroughly trans-contextual such as obesity, it has a tendency to be systematically wrong. The authors claim that these gross errors are directly related to a fundamental misconception about the role of complexity in health.
When Gregory Bateson was asked how to deal with the burgeoning complexity in the healthcare system in (1970s!) California, he advised adding complexity. Complexity in this view is a resource not a problem. This paper explores that insight.
Evidence of efficacy in healthcare purports to rely on data about patients. Statistical techniques make an implicit assumption that patients are at some level normative. Complexity becomes important because in practice patients have many life contexts that make them different. These differences include their symbiotic bacterial environment, their family and social circles, their economic status and employment, their mental world and their diet. These contexts are far from passive and all learn from each other and make adjustments to each other (symmathesy).
A healthcare system cannot be removed from the many contexts that it exists within. Therefore it also cannot be isolated and “fixed” without consideration of the ways in which, as a system, healthcare woven into society. Below is a brief and incomplete illustration of the process of providing a transcontextual description of healthcare. These are abbreviated questions, provided to encourage the beginnings transcontextual description of the ways in which healthcare is interrelated to societal institutions.
Economics: What effect does wealth gap have on health? Is the medical system supported by private or public funds? How is employment and long term illness addressed? How are the expenses of early childhood and parenting health calculated? Who is getting rich? Who is getting poor?
Education: How is the society educated about health? What kind of habits are being taught to citizens? How has the pharmaceutical business shifted the education programs teaching doctors? What kind of support is available in schools for children with medical needs?
Politics & law: Are industries supported that are destructive of health? How are regulations monitored that protect the health of citizens? Are politicians representing citizenry or industry in their policies toward medicine? How can the industries that profit from health threatening products share their wealth with the medical systems that are responsible for treating the illness produced by large money-making businesses like: sugar, pesticides, tobacco, agricultural mono-cropping, pollution, chemical waste and use, and so on…?
Media: What is the image of health that is portrayed? Are advertising habits contributing to depression, consumption of toxic products? How does a society view illness? Is the media generating community engagement, or not? What is the responsibility of journalism is covering health risks, treatments and lifestyles?
Religion: What are the spiritual considerations of health? How are religious communities supporting the health of their members? How can religious or spiritual practice be considered by the healthcare system?
Culture: What sort of ideas about health are alive in the culture? What are the holiday traditions? Cultural expectations (etc) that address health? How does the culture view the responsibility of health? Do medical systems take anthropological cultural differences into account in diagnosis and treatment?
Technology: How is technology effecting the health of youth? How can technology be helpful in treatment and records of patients? How has the potential of technology been underestimated, and overestimated? Who profits? Who suffers?
Ecology: How is the health of our bodies dependent upon the health of the ecology? Air, water, food, and necessities of probiotic bacteria all connect health inextricably from the larger ecological systems. How is our health care system aligning or isolating from the science of ecological interaction?
The reader may notice that these are false separations, and that these questions loop back into each other. This is an essential truth. These aspects of our lives are inseparable, and the inseparability of them is crucial information to be brought to the fore and vocalized. Economy and health and education and ecology and … they are not cogs in a machine that can be replaced. They are melted together into what we know as day to day life. Health therefore is about how the people within a society exist within these conditions.
The complexity of health production (and dysfunction) is mostly about the way these contexts interact in the life of a patient, whether or not the concept of a normative patient is seen to be helpful or not. Each particular patient has both interactions between these contexts (such as the two-way interaction between diet and the gut biome) and narratives about that interaction that affect behaviours. This type of complexity is irreducible and attempts to reduce it simply add to complexity in unexpected ways. To call any of these effects secondary, or contingent, or externalities is in our view simply an unhelpful narrative. Medical theory that is premised on an understanding of the body as isolated from its unique context contains reductionism that it is time to leave behind.
Transcontextual description and the consideration of studying the comparisons between the two systems of the human body, and the healthcare system is an entrance into the real task of developing another kind of information with which to analyse and assess complex systems. To study the health care system by removing the socio-economic and political contexts it must exist within will skew the information and subsequent decisions about how to improve the system. Similarly, removing the patient from the relationships with society and culture which define their daily lives will omit vast relevant detail to inform treatment, and diagnosis. Contextual, and transcontextual information is necessary in any inquiry of complex systems.
Warm Data is a new term that has been defined as: Transcontextual information about the interrelationships that integrate a complex system.
From the paper entitled Warm Data: Contextual research and new forms of information Nora Bateson writes:
“Although statistical data is useful, it is also limited by the common practice it often accompanies: decontextualizing the focus of inquiry. To study something is usually to pull it out of context and examine it in isolation. Rarely is the study re-contextualized to look at the complexity of its larger web of relationships. Warm Data circumnavigates the limitations inherent to statistical analysis by engaging a trans-contextual research methodology, bringing not only context, but multiple contexts into the inquiry process.
“In order to interface with any complex system without disrupting the cohesion of the interdependencies that give it integrity, we must look at the spread of relationships that make the system robust. Simply using analytic methods focused on parsing statistical (cold) data will often point to conclusions that disregard the complexity of the situation at hand. Moreover, information that does not take into account the full scope of interrelationality in a system is likely to inspire misguided decision-making, which compounds already “wicked” problems. Warm Data is not meant to replace or in any way diminish other data, but rather it is meant to keep data of certain sorts “warm” — with a nest of relations intact.
A change in results and findings, must follow a change in research methods. But to change research methods a mandate for another realm of information that includes context(s) must emerge. As it stands the information that is derived through exisiting silo-ed research methods is by definition insufficient to inspire treatment that addresses illness in contextual ways.
“Warm data is the product of a form of study specifically concentrated on (trans)contextual understanding of complex systems. Utilizing information obtained through a subject’s removal from context and frozen in time can create error when working with complex (living) systems. Warm data presents another order of exploration in the process of discerning vital contextual interrelationships, and another species of information.” ( N. Bateson, Warm Data)
This paper is demonstrating that complexity is a resource, indeed a vital resource, in coming to health. We are trying to support people making sense (and health) in a swirling set of contexts. To do so, a fresh perspective and epistemology is needed on how health is produced. For instance, if a patient’s obesity is associated with a felt loss of agency, then telling that patient how to control their weight is never going to work. Instead we need to allow patients to adjust their own meanings and narratives in an environment that does not actively subvert their health.
Myth of Objectivity and the violence of Objectification.
Science that presumes a stance of objectivity is possible neglects the necessary bias of its inquiry. Any direction a lens is pointed represents many other directions that have been discounted. Any question is an edited, cultivated, and ultimately subjective question. Although scientific research and the rhetoric of the field is intoned with language that communicates a message of objectivity, the work itself is always framed within the biases of culture, discipline, monetary feasibility, and ultimately the perspective of the researchers themselves. There is no such thing as objectivity: or rather, when it is attempted it becomes something other than what was intended.
However, the idea that the messy contextual influences that surround a “subject” of study can be objectified has very real consequences. To pull something out of its context is to sever it from its meaningful interdependencies. In the process of doing so, that “objectified” subject becomes vulnerable to exploitation. Objectification leads to exploitation, in human terms, in the natural world, and in science.
In his seminal book Slow Violence and the Environmentalism of the Poor, Rob Nixon talks about making visible the violence done over long timescales by the sort of colonial attitudes we note here. In the medium term of years and decades, bad dietary advice by health institutions can be seen to have killed millions of people. That is a tough statement even to write. It may also prove to be true that antibiotics have similarly killed millions, even though they have also saved millions of lives. We cannot address complexity while avoiding such perspectives. These are the larger circles of which we only see small arcs: the title of another seminal book this time by Nora Bateson.
What is the everyday connection between complexity and violence? Health can only be produced within the contexts and narratives of patient’s lives. To sever a patient from the contexts of their lives is an act of violence. Sometimes an intervention can be short and effective: nowadays all the important health problems do not look like that. The managerial pressure in healthcare systems to become more and more transactional requires reductionism. These transactional interventions almost all short-circuit the necessary complexity that produces health. These short-circuit interventions are all violent in the sense we are discussing here. Prescribing an obese person a strict diet is not going to allow the complexity of that person’s relationship to food to move into a healthy place, or even to be considered in the treatment.
The social dimension of this complexity is always about dominance: cultural, social, economic, political. Diagnosis, analysis and treatment are imbued with interpretation and judgment of the way patients live their lives. The meanings that healthcare professionals find in patient behaviour are not the meanings patients have for themselves. A patient’s relationships to health and the healthcare professionals they interact with are not blank canvasses. The interactions communicate notions of worthiness and / or inferiority implicitly as well as explicitly. All too often healthcare professionals insist on their own meanings in a way that disrupts the moral world of the patient. These relationships are essentially colonial, imposing what is seen as best for patients by professionals. The “problem” gets located in the patient and not in the patient’s many contexts where it could be dealt with. Never doubt that disrupting people’s moral world will also have health effects!
The data needed to work in a non-violent way is different to what counts as evidence in healthcare today. Warm data addresses the many contexts and meanings of a patient’s life. Warm Data is about relationships, and relationships do not stay they the same, nor can they abstracted or torn from context. Because it cannot be summarised into statistical bites Warm Data is huge and unwieldy. But warm data can be shown to avoid some of the gross errors that have arisen with conventional approaches to evidence. In healthcare, it is the very integrity of health that is at stake.
We can look at (anti-)colonialism or at feminism for clues as to how the imposition of meaning on patients is self-defeating. There is a dreadful history of all the things that the “natives” of colonised countries in Africa and Asia were (and indeed, are) not able to do for themselves. We locate this observed “incompetence” in the people and their culture not in the disruptions of colonial regime. We still talk about economic assistance while removing the necessary capital from those countries. There is a similar history of all the things that women were deemed not to be good at, including at the turn of the previous century, languages, when a diplomat was the high status thing to be. The evidence for these effects and the inferiority of the groups in question was and is every bit as good as the evidence relied on in healthcare. We can extrapolate, therefore, to the notion that patients will be “incompetent” in many of the skills that healthcare sees as necessary.
My own (AW) recent experience of being diagnosed as type 2 diabetic, has a been a comedy of people telling me what I must do and being wrong in the most basic ways, in ways that would certainly worsen my condition. I have had to educate myself about the basic science and the treatment options including dietary control, against the opposition of the medical professionals. I have heard interviews with senior professionals who become shrill and in some cases violent when their recommendations are challenged. Tim Noakes, a prominent South African professor of sports science and nutrition, was recently put on trial in South Africa for promoting a high fat diet. These things are understood to take place, but their link into a misunderstanding of complexity and the role of warm data is not yet established.
In warm data, all the meanings that stem from the various contexts are valid even if contradictory. As with much systems science ambiguities and contradictions generally mark fruitful areas for exploration and questioning. There is no thought of trying to find the “right” answer, indeed rigour is directed at making sure as many contexts as possible are taken into consideration when decisions are being made. This is the key first step in making complexity a resource: instead of trying to back ourselves into a corner, we keep many degrees of freedom open at all times. Revisiting previous decisions and conclusions is the norm. The facts are allowed to change and no-one need get upset.
The appropriate response to violence to a community and its health is community action and resistance. Imposed healthcare meanings are destructive both of individual lives and of the health of community. These aspects of health need to be reasserted if healthcare is to regain its ability to provide help and support.
Fractured and destructive policy
News reports and research studies typically talk about demand for healthcare, as though the numbers of people queuing up at A&E were some sort of act of God. When we ask about patterns it is clear we need to have a different conversation. We note that:
1. Almost everyone counted as demand is an existing patient of the healthcare system: from this perspective they are there because previous interventions in their health fell short in some way
2. Where “demand” rises sharply in areas like cancer and auto-immune conditions, the likelihood has to be that the environment (taken very broadly to include for example food and work stress) has become toxic
3. For whole swathes of the population, obesity, low rates of exercise, alienation, lack of work-life balance, high levels of stress etc. become normative so that people no longer look for answers or ways out
These patterns are an example of integrative thinking, linking policy questions across domains that are kept separate in policy-making. The question of whether the licensing of glyphosate under intense corporate pressure will actually bankrupt healthcare is never asked. The environment minister wants to sanction the use of extremely harmful chemicals into the physical environment (there is glyphosate in rain) if it can’t be proved in public to be harmful. A health minister presumably has a very different view of the risks to his budgets but that is not his job. Transport policy actually came up in the news when the air quality in many inner-city schools was seen not to reach safe levels. Here education policy, transport policy and health policy coincide publicly, but the chance is not taken to integrate the understanding of the world that could result.
Michael Marmot reports that in Norway all government ministers are prepared to say they are ministers of health in addition to their own portfolio. They know at least that every decision they make will affect the health of the population (and beyond). This is to recognise the fragmentation but not necessarily to integrate the concerns. All the interesting policy effects are in the interaction between policies in different policy domains. The thinking is fractured and the evidence that is invoked is subject to the same fractures. The natural and irreducible complexity is held to be simplified by government fiat into problems that can be solved by government ministries with the occasional reshuffle and reorganisation.
Not all policy interaction is negative. For instance, the soil is a massive reservoir for carbon dioxide: good agricultural policies about conserving and improving soils have massive positive effects on climate change. The positive interactions seem as difficult to get action on as the negative interactions.
The very idea that we could usefully study (still less manage) demand on healthcare services is a barometer of how little our epistemology supports dealing with the pressing problems that we have. We make complexity our enemy in embedding simplifying assumption into our policy process. Warm data persuades us to do the opposite. It turned out that residents of Grenfell Tower, in their concern for their own lives were better able to integrate data and had a more informed risk assessment than the highly trained and well-resourced experts. There is a story about corruption and greed but there is also a narrative about who can do trans-contextual work.
We can summarise this section by saying that our policy generation systems are far from being healthy. There is a case for saying they are terminally ill in being unable to find policies that allow other parts of society to function well. This is emphatically not because the issues are too complex, it is because the vital, necessary complexity is refused and denied, in the name of authority and leadership.
The ecology of health: some cases
The authors have a broad project going in the UK to apply the notions of warm data to make complexity a resource. It looks to correct some of the most grievous mistakes visible in the relationship between health and healthcare today. These mistakes include:
· The dietary advice from PHE which is complicit in the rapidly escalating levels of obesity
· The treatment of type 2 diabetes including the refusal to treat it as reversible
· The withdrawal of community support for people with sickle cell in Brent
Our questions about obesity turn on two related questions. Firstly, why mistakes and poor science in the 1950’s still drive bad policy on health advice: why is learning seemingly impossible? Secondly why does obesity attract personal blame and why is it seen to be a moral failing? The more enlightened discussion talks of obesogenic environments in which many or most people are tending towards obesity. Our research is into ways in which communities can make their own environment less obesogenic. Such research is highly trans-contextual and is far from looking for key factors or scalable programmes.
One frame for the lack of learning is how individual patient stories get framed as anecdotal. I have a gut feeling for how this plays out. A GP gives standardised dietary advice, is paid to do so. The advice doesn’t work for a particular patient. The patient is clearly at fault for not following the proven and standard dietary advice. The patient’s experience is completely discounted and the advice is given more vehemently and is more obviously valuable and correct. The patient’s sense of their own body and what it needs is thrown into question by authority. This story and its variants must have played out many millions of times. How can all those doctors manage not to react to the evidence in front of their eyes? Surely this is a question of epistemology, not a mistake in the findings of research.
Our initial research response to the question of obesity is to approach through the contexts not usually included. Issues of placemaking and turning a community into a more exciting and sought-after location might combine with developing local businesses and employment opportunities. Integrating that with the notion of local food growing and small food businesses would give people a totally different learning stance to how their bodies react to the environment. When we talk about complexity as a resource we are talking about an approach where different contexts give people a way to circumvent situations where they are otherwise stuck.
Our questions about type 2 diabetes are more pointed because the biomedical narrative by the healthcare industry is so much more forceful. Here is violent intrusion into peoples’ lives on a basis that lacks evidence. The Hba1c numbers override anything the patient can do or say. Why? Where is the sense that a patient can and indeed must understand what their body is responding to and how resilience in body mechanisms can be regained? (My own case (AW) and that of my pregnant daughter indicate it is mainly stress that derails these mechanisms. )
The warm data approach indicates that the various meanings the patient finds in their various contexts are all relevant and significant. For instance, stress can be a subtle thing to deal with. But there is also a time dimension to this warm data question. Many of the contexts of life shift and change and not always in visible ways. The microbial context both inside and outside my body adjusts to my diet and to other contexts. That means that what I learn today about what to eat and how much exercise I need will indeed be different in six months’ time. The way my body signals hunger for instance clearly adapts to a dietary change on a three-month time scale: this makes the learning journey continuous and makes any standardised advice a clunky tool.
Type 2 diabetes clearly cannot be understood one patient at a time. The explosive growth in number of diagnoses cannot indicate that people are suddenly making unwise choices in their lives any more than it can indicate genetic causes. The pharmaceutical companies see the numbers as a bonanza and put pressure on the prescription of their drugs for the rest of people’s lives. It is in this frame where very little of what is occurring in a patient’s body has its main locus of causation in any of the patient’s behaviours, that peddling descriptions of the cellular level processes that are just wrong, and recommending diets that are also just wrong is so intrusive and insulting. How did we get there? How can we get somewhere that supports patients in learning what they actually need to do? It is the approach to both research and treatment that is being overwhelmed by conditions such as type 2 diabetes.
The particular case of people living with sickle cell disease in Brent (NW London) highlights some of the more visible, albeit unintentional, violence in healthcare. Sickle cell is rare enough that physicians of all sorts will see it occasionally at best. When a sickle cell patient has a crisis they are in extreme pain and need a quick response with morphine and hospitalisation.
· There used to be a protocol in A&E for treating these patients. It has been “lost” so patient are given paracetamol to see if that works for their pain.
· People who are severely affected are often on Disability Living Allowance. Lately that benefit has been withdrawn meaning in practice patients have to “sign on” at the Jobcentre once a fortnight. Cold weather is a common trigger for a crisis and this forces them to go outside.
· Even, perhaps especially, when a patient’s employer is a healthcare institution, patients find that they need to educate their employer into the nature and implications of their condition. Patients find this lack of understanding one of the major stresses in their lives.
· A community support programme was axed because the health commissioners could not produce data to support the effectiveness of the programme against their own business case.
These people need their own medical data in order to have significant conversations in many contexts of their lives. This data is far from being available or in suitable form for their purposes and we are piloting a project to allow people to collect and make sense of their own data for these purposes.
Many people pay lip service to the notion that true complexity is inseparable and then try to manage parts of a system separately. Healthcare is a paradigmatic example. From within healthcare, professionals are building theory, knowledge and practice that defines what counts as an issue or a factor and what is outside their purview. And the issue of health as we know it is sufficiently complex that they can convince themselves they are making progress.
This paper talks about transcontextuality. There are many contexts that are implicated in health and in the epidemics of non-communicable diseases that we are witnessing. These contexts, some of them listed and sketched above, are treated by our culture are separate, and society and government attempt to govern and manage them as though they are separate. However, they all accommodate themselves to each other in ways we deny or think are secondary because we have arranged not to handle these interactions. The contexts learn from each other. This is a dynamic situation that fundamentally cannot be separated.
We have sought to demonstrate that our current research procedures can lead to gross error, to killing the people healthcare looks to care for. The research procedures are deeply flawed and deeply embedded so that researchers are protected from the knowledge of the results of their work. There are alternative research procedures that do not rip research data from its contexts, and these procedures are designed to be much safer than the existing approaches.
There is a way to cut through this debate to find out what is broken. We can check the various conversations and semiotic channels necessary to successful learning and adaptation to our fast changing world. We can discern whether two-way communication is actually taking place. Such a picture of whether our health has a proper dynamic, ecological basis is actually foundational, though the authors are not aware of anyone working is this fashion.
… may God us keep, from single vision and Newton’s sleep. William Blake
The belief of the healthcare establishment seems to be that although mistakes can be made, the approach to research and evidence is sound and indeed is the gold standard. Double blind drug trials with sophisticated statistical evaluation are usually held up as the goal. These things have their place but they are far from being universally valid: the cliché here is the domain in which Newton’s laws of motion are valid.
Warm data is challenging to work with but can give us an idea of the domain in which conventional research may be useful and where it may introduce the sort of catastrophic errors described in this paper. Further, warm data allows us to understand complexity as a resource for people in living through the difficulties they encounter. The simplification we often find in the development of advice and guidance very often depletes or removes this resource, leaving people passive and institutionalised.
When the biomedical model becomes too central and centralised in the planning and delivery of healthcare we risk (slow) violence. The imposition of healthcare is much too prevalent. Disciplines such as medical anthropology have well developed critiques of this. The issue, however, is to have an alternative rigorous approach to understanding health and healthcare. Not alternative conclusions but an alternative epistemology to support compassionate research and context sensitive delivery.
The Ecology of Health, Robin Stott, Schumacher Briefings, 2000
Phenomenology of Illness, Havi Carel, OUP 2016
How to implement evidence-based healthcare, Trisha Greenhalgh, Wiley-Blackwell 2017
Small Arcs of Larger Circles, Nora Bateson, Triarchy Press, 2016
Symmathesy: a word in progress, Nora Bateson, https://norabateson.wordpress.com/2015/11/03/symmathesy-a-word-in-progress/
Writing at the Margin, Arthur Kleinman, UCP, 1997