As described previously in this journal, systems thinking recognizes the importance of cooperation. The whole is larger than the sum of its parts. Whole new properties (such as life) can emerge when individuals form communities and when systems form. Moreover, systems thinking is an essential part of modern medicine. Physicians, nurses, research institutes, charities, governments and pharmaceutical companies are all cooperating to prevent illness, find cures for diseases and help us all live long, healthy lives in communities that care about all their members, especially the most vulnerable.

Sadly, there is a loud minority that believes that we are all in a secret conspiracy to keep everybody (including ourselves) sick. We only make medicines that treat symptoms, but don’t cure anything. The goal is to maximize profits by getting people addicted to prescription drugs that all have terrible adverse side effects. Moreover, vaccines don’t work and the doctors who push them should be jailed or executed. This is wrong and leads to much suffering and death. The only people who gain from this are those who get paid by radio, television, and/or social media to spread such lies and link them to a male God and fascism.

Actually, we are in an open collaboration to help save lives. We work to provide a health care system and medicines that are predictive, preventive, personalized and participatory (P4 medicine). We can predict a person’s susceptibility to diseases as well as the effects of any genes, such as those that can help cause breast cancer (the BRCA genes). This way, we can ensure that the right people are recruited into clinical trials. For example, when a prospective new drug is intended to target the BRCA1 gene, it’s best if only people who have that mutation are included in the trial. Also, we can provide good advice on diet and lifestyles that can help prevent diseases, as well as unhealthy foods, dietary supplements and habits that can cause diseases.

So, P4 medicine is personalized. One size does not fit all. We treat the patient as a whole person, instead of focusing on a single problem. We also realize that almost everybody, patients and caregivers, want to participate in this. So, there are crowd sourcing efforts to enable individuals to work from home (or anywhere) to develop new drugs. Examples include Fightaids@Home (run by the Scripps Research Institute) and Eterna, a browser-based "game with a purpose"1-2. It was developed by scientists at Carnegie Mellon University and Stanford University. It engages users to solve puzzles related to the folding of RNA molecules. As described previously in this journal, RNA technology is used to make vaccines for COVID-19 and is being tested in clinical trials to cure many diseases, including cancer 3.

The World Health Organization (WHO) uses systems thinking as an approach to problem-solving 4. They view problems as part of a wider dynamic system. It recognizes and prioritizes the understanding of linkages, relationships, interactions and interdependencies among the components of a system. These give rise to the system’s observed behavior. Systems thinking is a philosophical frame that can be used as a method with its own tools. Systems thinkers realize that actions or changes in one aspect of a health system are likely to affect what happens in another. Systems thinking is important in Health Policy and Systems Research (HPSR). Health systems research considers the functioning of the health system, the costs and quality of the services provided, and the distribution of resources within the system. Biological, behavioral, and social research is important tools for public health research. This allows for a more adaptive implementation of health system policies and programs.

The Systems Thinking for Strengthening District Health Systems (ST-DHS) initiative is running in partnership with the Swiss Tropical and Public Health Institute in Botswana, Timor-Leste and Pakistan. Its aim is to make systems thinking routine in the practice of district health managers. To that end, it prioritizes capacity development in methods, data analysis and reflective practice.

There is also an Alliance for Health Policy and Systems Research. It is developing a Systems Thinking Accelerator to support the global community of practice on systems thinking. It aims to increase the field of applied systems thinking in low and middle-income countries. It provides a platform for exchange of ideas and advocacy for systems thinking. The Alliance aims to create a wider and more inclusive community of system thinkers around the globe.

According to the American Medical Association (AMA), physicians must understand all parts of the health care system - from the emergency department to the primary care clinic, from the patient’s family to community organizations - and critically think about how all these moving parts can work together to improve patients’ health, meet their health care needs and anticipate and mitigate safety threats or other problems5. Systems thinking helps provide better patient-centered care, fosters problem-solving and encourages questioning.

Systems thinkers:

  • Seek to understand the big picture.
  • Observe how elements within a system change over time, generating patterns and trends.
  • Recognize that a system’s structure generates behavior.
  • Identify the circular nature of complex cause-and-effect relationships.
  • Make meaningful connections within and between systems.
  • Change perspectives to increase understanding.
  • Surface and test assumptions.
  • Consider the issue fully and resist coming to a quick conclusion.
  • Consider how mental models affect current reality and the future.
  • Use understanding of system structure to identify possible leverage actions.
  • Consider short-term, long-term and unintended consequences of actions.
  • Pay attention to accumulations and their rates of change.
  • Recognize the impact of time delays when exploring cause-and-effect relationships.
  • Check results and change actions if needed, a process known as “successive approximation.”

The AMA has released the second edition of the Health Systems Science textbook6. It is the first text that focuses on providing a fundamental understanding of how health care is delivered, how health care professionals work together to deliver that care, and how the health system can improve patient care. There is also a review book entitled Health Systems Science Review 7. It is a first-of-its-kind review book created by the consortium and published by Elsevier. This study tool provides case-based questions followed by discussions of answers and suggested readings—making it a valuable review resource for medical students and instructors, as well as resident physicians, hospital administrators, and nursing, allied health, and public health students.

The AMA also has an education module 8. It helps medical students, residents and practicing physicians understand the importance of systems thinking in clinical care. It aims to teach how to adopt the habits of a systems-thinking health professional. The goals are better patient experiences, better population health, lower overall costs and improved professional satisfaction.

The United States government is also deeply involved in this collaboration of systems thinkers. For example, the Food and Drug Administration (FDA) has a Center of Drug Evaluation and Research (CDER) and a Center for Biologics Evaluation and Research (CBER). They are developing a more systematic approach. They listen to the voices of the patients and their caregivers. The goal is to build on the series of public workshops that occurred under the current patient-focused drug development program. This is being used to produce guidance to assess the burdens of diseases and the treatments that are most important to patients, as well as impact measures, clinical outcome assessments, and endpoints to inform drug development and regulatory decisions.

The FDA and other governments’ regulatory agencies evaluate applications for new medical devices, biological products and drugs. Before the Critical Path Initiative (CPI) was launched in 2004, the FDA was facing cuts in resources, while industry was facing technical challenges and a set of partly outdated regulations. Also, there had been an unacceptable decline in the number of new drugs getting through all four stages of clinical trials and subsequently being approved, despite the enormous breakthroughs being made in biomedical science. So, the FDA established the Office of Critical Path Programs (OCPP) in the Office of the Commissioner to support the initiative.

Since globalization, rapidly evolving technologies and emerging areas of science were having an increasing impact on all FDA-regulated products, So, the CPI gradually expanded its scope. They used knowledge gained from new scientific discoveries to improve the tools used in human and animal medicine and food safety. It included rapid analytical methods to detect biological and chemical contaminants in foods. The CPI continues to support many projects related to streamlining information management systems for all agency-related information about medical products. This includes encouraging electronic submissions and reporting negative side effects while analyzing human and animal food. For detailed information on CPI, the FDA has a website for it.

The FDA’s Center of Drug Evaluation and Research (CDER) has funded research that has led to many excellent publications. This includes developing process analytical technologies, doing root cause analyses for drug product recalls, standardizing spectral libraries for rapid screening of pharmaceuticals, improving knowledge management tools for creating a cross-disciplinary multiple-NDA (New Drug Applications) disease database. CDER also encourages quality by design, systems biology, computational modeling, streamlining clinical trials and much more.

At the same time, the NIH supports the Community Child Health Network (CCHN) at the University of California, Los Angeles (UCLA) 9. They have found that the preconception period strongly influences the outcomes of pregnancy and the health of the child. It is a multidisciplinary effort that uses community-based participatory research. They are developing a novel, integrative theoretical framework to design future investigations, integrate new findings, and identify promising, evidence-based interventions to improve intergenerational health and reduce disparities. The CCHN uses a Preconception Stress and Resiliency Pathways (PSRP) model. It builds local and multi-site partnerships between the community and academia. They are establishing guidelines for planning research and making decisions. They review relevant findings from diverse disciplinary and community perspectives to find out where stress and resilience exist within families and communities. The PSRP model focuses on interrelating the multiple, complex, and dynamic biosocial influences that may be linked to disparities in family health. The PSRP model borrowed from and then added original constructs relating to the developmental origins of lifelong health, epigenetics, and neighborhood and community influences on pregnancy outcome and family functioning.

The FDA and other governments’ regulatory agencies are also collaborating in the One Health Initiative. The One Health Initiative is a movement to forge co-equal, all-inclusive collaborations between physicians, osteopathic physicians, veterinarians, dentists, nurses, and other scientific-health and environmentally related disciplines, including the American Medical Association, American Veterinary Medical Association, American Academy of Pediatrics, American Nurses Association, American Association of Public Health Physicians, the American Society of Tropical Medicine and Hygiene, the Centers for Disease Control and Prevention (CDC), the United States Department of Agriculture (USDA), and the U.S. National Environmental Health Association (NEHA).

The health of people, animals, and the environment is intertwined. A health hazard for people may likely be a health hazard for animals. Medical advances in understanding and treating a disease in one species, such as heart disease in people, may be applied to other species. A change in the environment can affect all living things, from people to animals to plants. For example, the Covid-19 pandemic was probably caused by people encroaching on new habitats and bringing bats that were infected with the SARS-CoV-2 virus into the open air market in Hunan, China. As humans continue to encroach on previously sparsely inhabited ecosystems, new zoonotic viruses may emerge.

The One Health Initiative recognizes this inter-connectedness and advocates a comprehensive approach to health and environmental problems versus a piecemeal approach. By building bridges between physicians, veterinarians, environmental scientists, and public health professionals, the initiative aims to “promote, improve, and defend the health and well-being of all species.

We are all in this together. For humanity to survive, we must do a better job of working together to solve the problems we all face from global climate change and other threats to public health. There is a group called the International Society for the Systems Sciences (ISSS) that is supporting this effort 10. It is a global community connected through systems theory, science and practice. The ISSS is a community of researchers, learners, and practitioners who are devoted to transdisciplinary inquiry into the nature of complex systems and the application of systems approaches for transformative change.

References

1 The Scripps Research Institute. FightAIDS@Home. HIV Interaction and Viral Evolution Center (scripps.edu).
2 Eterna. Eterna is an online game that invites everyone to help advance medical research. You play by solving puzzles using RNAs, tiny molecules at the heart of every cell.
3 Smith, R.E. Vaccines based on modern RNA technology. This technology's potential for vaccines and other diseases. Meer, 24 December, 2020.
4 The World Health Organization (WHO), Alliance for Health Policy and Systems Research. Systems Thinking.
5 Henry, T.A. Why you need to be a systems thinker in health care, American Medical Association.
6 Skochelak, S.E, ed. Health Systems Science. Elsevier, 2020.
7 Gonzalo, J.D. & Ehrenfeld, J.M. Health Systems Science Review, 1st ed. Elsevier, 2020.
8 AMA Ed Hub.
9 UCLA. Community Child Health Network (CCHN).
10 International Society for the Systems Sciences.