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. 2019 Mar 28;6:59.
doi: 10.3389/fmed.2019.00059. eCollection 2019.

Health and Disease-Emergent States Resulting From Adaptive Social and Biological Network Interactions

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Free PMC article

Health and Disease-Emergent States Resulting From Adaptive Social and Biological Network Interactions

Joachim P Sturmberg et al. Front Med (Lausanne). .
Free PMC article

Abstract

Health is an adaptive state unique to each person. This subjective state must be distinguished from the objective state of disease. The experience of health and illness (or poor health) can occur both in the absence and presence of objective disease. Given that the subjective experience of health, as well as the finding of objective disease in the community, follow a Pareto distribution, the following questions arise: What are the processes that allow the emergence of four observable states-(1) subjective health in the absence of objective disease, (2) subjective health in the presence of objective disease, (3) illness in the absence of objective disease, and (4) illness in the presence of objective disease? If we consider each individual as a unique biological system, these four health states must emerge from physiological network structures and personal behaviors. The underlying physiological mechanisms primarily arise from the dynamics of external environmental and internal patho/physiological stimuli, which activate regulatory systems including the hypothalamic-pituitary-adrenal axis and autonomic nervous system. Together with other systems, they enable feedback interactions between all of the person's system domains and impact on his system's entropy. These interactions affect individual behaviors, emotional, and cognitive responses, as well as molecular, cellular, and organ system level functions. This paper explores the hypothesis that health is an emergent state that arises from hierarchical network interactions between a person's external environment and internal physiology. As a result, the concept of health synthesizes available qualitative and quantitative evidence of interdependencies and constraints that indicate its top-down and bottom-up causative mechanisms. Thus, to provide effective care, we must use strategies that combine person-centeredness with the scientific approaches that address the molecular network physiology, which together underpin health and disease. Moreover, we propose that good health can also be promoted by strengthening resilience and self-efficacy at the personal and social level, and via cohesion at the population level. Understanding health as a state that is both individualized and that emerges from multi-scale interdependencies between microlevel physiological mechanisms of health and disease and macrolevel societal domains may provide the basis for a new public discourse for health service and health system redesign.

Keywords: complex adaptive nature of health; disease networks; emergence; health; health system redesign; physiology of health; psychoneuroimmunology; top-down and bottom-up causation.

Figures

Figure 1
Figure 1
(A) Community Epidemiology and (B) Diagnoses Distribution Resulting from Primary Care Consultations. The “ecology of medical care” has shown that the Pareto distribution applies to the need for health care−80% of people are healthy or feel healthy enough not to require health care; of the remaining 20%, 80% solely require primary care services (16% of the total), of the remaining 20%, 80% require secondary care (3.2% of the total); and the remaining 20% require tertiary care (0.8% of the total). Vice versa, Braun's studies showed that 80% of all primary consultations result in 20% of all diagnoses (mostly unspecific), the remaining 20% of consultations cover 80% of all diagnoses (4). The key message from these studies is that subjective health/illness experience and objective disease/diagnosis often do not coincide—the majority of people who may have symptoms but no or little illness experience rightly do not report to a care provider, although some will ultimately be found to have an identifiable disease, and many people who seek help because of their degree of illness experience ultimately do not have objectively identifiable disease.
Figure 2
Figure 2
Rothman's model of the “multiple different combinations of sufficient causes” of disease [adapted from Rothman (7)]. (A) Rothman's model of the “multiple different combinations of sufficient causes” illustrated in relations to “falls in the elderly.” As Rothman explained: “A specific effect [a fall in the elderly] may result from a variety of different sufficient causes [three causes are illustrated]. The different constellations of component causes [Tremor, Joint Deformity, Visual Impairment, Muscle Weakness, Arthritis, Hearing Loss, Cardiac Arrythmias, Balance Disorders, Peripheral Neuropathy, Charcot's Foot] which produce the effect may or may not have common elements. If there exists a COMPONENT CAUSE which is a member of every SUFFICIENT CAUSE, such a component is termed a NECESSARY CAUSE [in this case: only “Tremor” is a necessary cause]. [The f]igure suggests many synergistic relationships. For example, “[Arthritis]” and “[Muscle Weakness]” are completely synergistic with each other and each is partially synergistic with “[Tremor],” “[Joint Deformity],” and “[Visual Impairment].” Partial synergy exists between “[Joint Deformity]” and “[Visual Impairment]”—their effect is dependent on their joint presence in one sufficient cause, but each also has independent effects in another sufficient cause [“Joint Deformity” in Sufficient Cause II, “Visual Impairment” in Sufficient Cause III].” (B) Rothman's model can be applied to the EMERGENCE of HEALTH and ILLNESS STATES in the presence and absence of disease. In the example “Life is Worth Living” and “Happy Relationship” are two components necessary for the emergence of the two “HEALTH STATES” (1) and (2), and “Life is a Constant Struggle” and “BMI 34” are two components necessary for the emergence of the two “ILLNESS STATES” (3) and (4).
Figure 3
Figure 3
Four “Mutually Agreeable” Conceptualisations of Health and Disease. (A) Bircher's model defines health as an im/balance between the two acquired potentials and the demands of life (biologically given and personally acquired resources). The relationship between the total potentials and the demands of life determines, whether an individual is in a health (potentials > demands or demands < potentials) or disease (demands > potentials) state. Note: Health can be achieved despite a reduced level of the potentials (40). (B) Macklem describes life/health as a transition phenomenon. His [s]chematic illustrate[s] the continuum of open thermodynamic systems from ordered, near-to-chaotic, [to] far-from-equilibrium states. As energy consumption increases, systems move further from equilibrium and pass through a phase transition between order and deterministic chaos. Complex systems, like life [and health], exist in this phase transition (44). (C) Soodak pointed to Bernard's principle of the constancy of the internal environment (that is, homeostatic regulation, which may be both cyclic and adaptive) as the condition of free and independent life, is the first approximation to a theory of the organism. He suggested the new physical doctrine of homeokinesis as a second proximation to such a theory of complex autonomic systems. Recognizing the natural hierarchy of organizational levels allows a dynamic regulation scheme that allows the homeostatic persistence [to be] maintained by the action of chains of thermodynamic engine processes, [i.e., physiological interactions across all scales of human existence] (32). (D) Health, as an attractor, maintains a dynamic equilibrium over time. Thus, health cannot be “one” particular state, but rather a relative point in a phase space, i.e., health is a chaotic attractor. Three attractor patterns emerge; a health attractor around the center of the somato-psycho-socio-semiotic phase space, with illness, dis-ease, and [acute self-limiting] disease occur on “more distant orbits” of the attractor; a chronic disease attractor—here—centered toward the somatic corner of the phase space (but can be any other corner); and a “psychosomatic attractor” whose dynamics swap between two phase space areas, the physical and the psycho-semiotic (16).
Figure 4
Figure 4
The Top-Down and Bottom-Up Interdependencies of Health and Disease. The model highlights the key “networked” relationships between the external factors and internal mechanisms of the person's health and illness experiences. formula image exaggerating effect.

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